Colorectal SSI Reduction and Collaboration with the Center for Transforming Healthcare Lessons I Learned Robert R. Cima, MD 2012 ACS NSQIP National Conference July 22-24, 2012 2011 MFMER slide-1
Mayo Clinic, Rochester Tertiary care, academic medical center 1,200 licensed beds St Marys Hospital (SMH) Rochester Methodist (RMH) Colorectal surgery is performed at both hospitals SMH only absolute emergency CRS cases (~100 operations/year) RMH elective and urgent CRS cases (2,500-3,000 operations/year) 2011 MFMER slide-2
RMH Colorectal Surgery Practice Full spectrum of CRS Benign anorectal to recurrent rectal cancers >50% of all colectomies performed using a minimally invasive approach Eight board certified colorectal surgeons General surgery residents 4 colorectal surgery fellows Dedicated CRS operating rooms and allied health staff Two dedicated CRS post-operative nursing floors 2011 MFMER slide-3
We were as Expected in CRS SSI 0.7 0.6 0.5 0.4 0.3 0.2 0.1 0.0-0.1 2011 MFMER slide-4 05/2006 07/2006 09/2006 11/2006 01/2007 03/2007 05/2007 07/2007 09/2007 11/2007 01/2008 03/2008 05/2008 07/2008 09/2008 11/2008 01/2009 03/2009 05/2009 07/2009 09/2009 11/2009 01/2010 03/2010 Proportion 05/2010 07/2010 Month/Year UCL 0.088 LCL=0.000
Why work with the CTH? Could We Improve? What Could We Learn? A chance to discuss SSI with other institutions Speaking a common language: NSQIP Share our data and experiences What were their SSI risk factors? What did people think were contributors to SSIs? What had people already tried in their institution? How to implement change in the OR? 2011 MFMER slide-5
Starting Point Stable NSQIP Overall Baseline SSI Rate 0.7 0.6 0.5 0.4 0.3 0.2 0.1 0.0-0.1 2011 MFMER slide-6 05/2006 07/2006 09/2006 11/2006 01/2007 03/2007 05/2007 07/2007 09/2007 11/2007 01/2008 Proportion 03/2008 05/2008 07/2008 09/2008 11/2008 01/2009 03/2009 05/2009 07/2009 09/2009 11/2009 01/2010 03/2010 05/2010 07/2010 Month/Year UCL 0.088 LCL=0.000
Critical to Quality Tree: SSI for Colorectal Surgery Chlorhexidine cloths @ AM admission Pre-operative Processes Intra-operative Processes Patient Cleansing Antibiotic administration Hibiclens shower night before and day of surgery Ensure understanding by reading pamphlet Preventing SSI Ensure SCIP compliance 1. Right antibiotics 2. Administer 60 min prior to incision 3. Discontinued with in 24 hours Ensure re-dose of cefazolin with in 3-4 hours after incision Chloraprep applied use appropriate amount to ensure complete coverage of incisional area Reduce SSI by 50% (10 5%) Closing protocol @ time of fascia closure Use Closing tray for closure of fascia and skin Glove change by staff before closure of fascia Practice good hand hygiene Patient shower with Hibiclens following dressing removal Postoperative Processes Patient and Hand hygiene Hand Cleansing agent readily available Signage encouraging hand hygiene Purell hand wipes made available to patients Ensure dressing removal with in 48 hours Posthospitalization Processes Dismiss patient with 4 oz. bottle of Hibiclens Patient education on wound care and recognizing infection symptoms Follow-up phone call from nurses 2011 MFMER slide-7
Project Year 2011 Go live with all process changes by January 1, 2011* (some IT changes released 4Q10) Maintain standard NSQIP sampling method Monthly audits of compliance with process steps Education and reinforcement of staff and residents Monthly reviews of SSI events 2011 MFMER slide-8
Percentage Chart of Total Observed SSI by Phase 0.4 2009 2010 2011 0.3 Proportion 0.2 0.1 0.0 UCL=0.2092 _ P=0.0421 LCL=0 Jan-09 May-09 Sep-09 Jan-10 May-10 Sep-10 InfoMonth Jan-11 May-11 Sep-11 Tests performed with unequal sample sizes 2011 MFMER slide-9
What I Learned from the Collaboration SSIs are a local, institution specific process Patient mix is different Disease mix is different Risk factors for SSI are different While we all do the same things, we all do them in very different ways Facilities strongly influence process Personnel Processes Traditions Known or unrecognized 2011 MFMER slide-10
What I Learned from the Collaboration Policies and processes are not the same You need to observe frequently Do not make assumptions that you know what is going on in the OR or the floor Don t look for a Magic bullet Too many variables in such a complex process so multiple smaller interventions across all aspect of care might be more effective Process variation is the Achilles heal or QI 2011 MFMER slide-11
What I Learned from the Collaboration You need reliable, actionable, and timely data NSQIP Process variation is the Achilles heal of QI It takes a team to accomplish change and achieve results 2011 MFMER slide-12
The Team Project Leader: Robert Cima, MD Black Belt: Gene Dankbar, Systems and Procedures Kimberly Aronhalt, RN, Infection Control and Prevention Diane Foss, RN, Kim Gaines, RN, Nursing, Pamela Grubbs, RN, Pamela Maxson, RN, PhD, Jennifer Wolforth, RN, Nursing Sharon Nehring, RN, Roxanne Hyke, RN, Diane Tyndale, RN, NSQIP Jenna Lovely, PharmD, Pharmacy Services Sarah Pool, RN, Surgical Services, Lynn Quast, RN, Surgical Services Jim Rogers, Systems and Procedures Rajesh Pendlimari, MBBS, Research Fellow, CRS Karen Piotrowicz, RN, Mid-level Provider, CRS 2011 MFMER slide-13
Questions & Discussion 2011 MFMER slide-14