Oscar Guillamondegui, MD, MPH, FACS Associate Professor of Surgery Tennessee Surgical Quality Collaborative

NSQIP 2014 A Collaborative that has Reduced Surgical Site Infections Tennessee Surgical Quality Collaborative Oscar Guillamondegui, MD, MPH Vanderbilt University Medical Center *Guillamondegui, OD, et al. Using the National Surgical Quality Improvement Program and the Tennessee Surgical Quality Collaborative to Improve Surgical Outcomes. J Am Coll Surg. April 2012; 709-714.

Disclosures: I have nothing to disclose *Guillamondegui, OD, et al. Using the National Surgical Quality Improvement Program and the Tennessee Surgical Quality Collaborative to Improve Surgical Outcomes. J Am Coll Surg. April 2012; 709-714.

TSQC Mission To improve the care of the surgical patient by supporting an open discussion and transfer of information through a collaborative team effort. Vision To identify best surgical practices, examine how the surgical team obtains best outcomes and teach other surgical teams how to improve outcomes.

Post-Op Occurrence Results Post-Op Complications* (Savings/10,000 Procedures) 2009 2010 Unit Costs NSQIP ROI Net Savings Per 10,000 Acute Renal Failure Graft/Flap Failure On Vent> 48 hours Superficial Incisional SSI 75.3 56.4 (-25%) $28,359 $535,985 45.8 18.1 (-60%) $14,851 $411,373 293.6 250.3 (-15%) $27,654 $1,197,418 357.6 289.9 (-19%) $27,631 $1,870,619 Wound Disruption 90.8 59.7 (-34%) $14,827 $461,120 Total 2010 Savings $4,476,515 *Guillamondegui, OD, et al. Using the National Surgical Quality Improvement Program and the Tennessee Surgical Quality Collaborative to Improve Surgical Outcomes. J Am Coll Surg. April 2012; 709-714.

Costs of Surgical Site Infections Literature review LOS increases 7-10 days Additional cost $20,000 THA* hospital billing data TSQC Patients with wound occurrence Average length of stay 7.2 extra days Additional costs $25,546 per case THA: Tennessee Hospital Association

Justification for Colectomy Focus High volume in all hospitals 8-9% of total TSQC cases 1250 colon cases (using our CPT groups) on average/year for the TSQC - Performed by large percentage of surgeons 188 different surgeon ID s Practice recommendations available Established outcomes rates NSQIP NHSN

Identifying a bundle No structured, recognized group of strategies to reduce risk of SSI Some data for specific interventions and practices, none for a group of practices. Some approaches have generated controversy SCIP Mechanical and antibiotic bowel preparation Hyperoxygenation

TSQC Requirements Level 1 or 2 data Not inflammatory to the surgeons Consider elements already in place (e.g., SCIP) Easily implemented case by case Able to be abstracted from the medical record Not mutually dependent: hospitals and surgeons can choose to participate in any or all of the elements Cheap

Bundle Options Oral antibiotics Skin prep prior to admission Glycemic Control Parenteral Antibiotics Mechanical Bowel prep Perioperative oxygenation Wound protection Anastomosis technique NORMOTHERMIA Skin prep prior to incision

The TSQC Colorectal Bundle Normothermia Glucose Control Appropriate antibiotic use Supplemental Fi02

Oxygenation Normothermia Glucose Control Antimicrobial prophylaxis ColectomyBundle Recommendation Evidence Summary Resource Summary Findings Comments A bundle of interventions to Implementation of Colorectal surgical site infection Small sample size reduce colorectal surgical Normothermia infections Normoglycemia Bull A, et al Oxygen delivery Appropriate antibiotics 15% > 7% (not statistically significant Difficulty to implement and maintain; low compliance with individual components Infection rates fell over the subsequent 12 months. Perioperative supplemental oxygen therapy and surgical site infection: a meta-analysis of randomized controlled trials Qadan M et al Perioperative Normothermia to reduce the incidence of surgical wound infection and shorten hospitalization Kurz et al Scientific Principles and Clinical Implications of Perioperative Glucose regulation and control Akhtar, S et al Antimicrobial prophylaxis for surgery: an advisory statement from the National Surgical Infection Prevention Project Bratzler DW et al Meta-analysis 5 RCTs Control FiO2.30 -.35; Study FiO2.80 for 2-6 hours postoperatively 30 day follow up 3 studies colorectal; 2 studies multispecialty Double-blind RCT demonstrating triple the incidence of SSI and pronged hospitalization in patients undergoing colectomy with intraoperative hypothermia Review article evaluating glucose control in the preoperative, intraoperative, and postoperative periods Consensus position statement from the Surgical Infection Prevention Guidelines Writers Group Surgical site infection rates 12% control; 9% hyperoxic. Relative risk reduction Greater benefit in colorectal procedures Surgical site infection in 19% of patients with intraoperative hypothermia and 6% of patients with intraoperative normothemia. Though there are unresolved questions regarding appropriate control it is prudent to maintain glucose levels < 180 mg / dl Optimal prophylaxis ensures that adequate concentrations of an appropriate antimicrobial are present in the serum, tissue, and wound during the entire time that the incision is open and at risk for bacterial contamination. Variable use of abx, blood loss among studies No standard definition of infection Significant improvement in all but one study, where SSI rate increased. Standard preoperative prep; cases riskadjusted for smoking, BMI, wound class, length of surgery. Clinical diagnosis of SSI. The authors site heterogeneity in many of the included studies as a limitation to the analysis; postoperative control appears to have the most significant effect on postoperative complications This article is a primary source document for SCIP guidelines

Clinical Application and Review Measure Recommendation Clinical Application NSQIP Abstraction Normothermia Maintain core temperature >36 during the perioperative period Check temperature prior to entering the operating room. Check every 15 minutes intraoperatively. Check immediately upon arrival in PACU and every 30 minutes until discharge from PACU. Active warming (e.g., Bair hugger) for patients with temp < 36. Abstract lowest intraoperative temperature. Normoglycemia Maintain blood glucose level < 200 mg/dl on the day of surgery and through the postoperative period Check blood glucose (all patients) prior to entering the operating room, and in the PACU. Institute sliding scale insulin coverage for blood glucose > 200, or per hospital protocol. Abstract the highest glucose on the day of surgery. Antibiotic use Appropriate antibiotic selection and timing per SCIP guidelines Administer antibiotics within 1 hour prior to surgical incision. Redose antibiotics if appropriate for operations lasting 3 hours or more. No abstraction; hospital will report SCIP Inf 1f, 2f, and 3f performance. Supplemental Oxygen Administer supplemental oxygen at 80% intraoperatively and postoperatively Deliver FiO 2.80 through the anesthesia circuit and postoperatively for 6 hours by nonrebreather. Review anesthesia record, postoperative order set, PACU record for intraop and postop delivery. Answer yes if the order is for FiO2.80. Answer yes if there is documentation that the patient received oxygen at.80. If there is no order, and no documentation of FiO2.80, answer no

Collaborative Implementation Fall 2011 Baseline data analysis Literature review and development of recommendations Leadership Committee review and approval Consensus approval from collaborative membership Winter 2011-2012 Collaborative implementation target: January 1 Trial implementation by Dr. Gibson SCR review and refinement of custom fields

Collaborative Implementation Spring 2012 Review of implementation progress: limited to individual surgeon preference in 6 of 10 hospitals Evaluation of support needs from members 10 Tennessee hospitals join NSQIP and TSQC Summer 2012 Status review with each hospital Early analysis of custom field utilization

Colon Bundle Update Total TSQC Cases 80,207 Cases w/glucose 26,745 Cases w/temp 28,119 Cases w/fio2 3,362 Total Colectomies 6,862 Colectomies w/glucose 2,711 Colectomies w/temp 2,849 Colectomies w/fio2 659 Colectomies w/all 3 613 Total Colectomies 6,862 Colectomies w/all 3 credible values 379 Of the 379 Cases w/ all 3 values in the credible range Measure Mean/SD Criterion Cases < criterion Cases > criterion Glucose 161.9/63 180 67.5% 32.5% Temperature 96.9/1.4 96.8 F 41.4% 58.6% This information is prepared and protected in accordance with the Tennessee Patient Safety and Quality Improvement Act of 2011. T.C.A. 68-11-272.

SSI Rates Year Total Cases Deep SSI Organ SSI Superficial SSI ALL SSI WD 2009 13469 107 196 459 762 104 2010 14893 112 255 411 778 89 2011 14681 74 192 393 659 63 2012 20956 125 214 437 776 140 2013 11987 80 108 250 438 77 Total 75986 498 965 1950 3413 473 Year Total Cases Deep SSI Organ SSI Superficial SSI ALL SSI WD 2009 13469 0.8% 1.5% 3.4% 5.7% 0.8% 2010 14893 0.8% 1.7% 2.8% 5.2% 0.6% 2011 14681 0.5% 1.3% 2.7% 4.5% 0.4% 2012 20956 0.6% 1.0% 2.1% 3.7% 0.7% 2013 11987 0.7% 0.9% 2.1% 3.7% 0.6% Total 75986 0.7% 1.3% 2.6% 4.5% 0.6% This information is prepared and protected in accordance with the Tennessee Patient Safety and Quality Improvement Act of 2011. T.C.A. 68-11-272.

Colectomy Operative Time v. All SSI Rate Decile Rank of Operative Time Operative Total SSI Cases Time (Hours) Rate (%) 1 427 0.91 8.4% 2 410 1.34 10.0% 3 440 1.63 12.1% 4 417 1.91 11.5% 5 420 2.16 12.1% 6 419 2.46 15.3% 7 429 2.82 17.7% 8 425 3.12 16.5% 9 425 3.87 20.7% 10 420 5.60 29.1%

Oscar Guillamondegui, MD, MPH, FACS Associate Professor of Surgery Tennessee Surgical Quality Collaborative