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Michael Timoney, MD, FACS Chief Quality Officer, NYU Lutheran
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Implementing a Colon SSI Reduction BundleDemographics of NYU Lutheran
• 450 bed “safety net” hospital • “Open door” access to care. • Ethnically diverse. • Large percentage of uninsured, Medicaid, and other vulnerable patients
• Teaching Hospital
• Level 1 Trauma center
• Number of colectomies / year
• 2014 = 164
• 2015 = 106 (YTD)
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Implementing a Colon SSI Reduction BundleThe Team
• Monthly Meeting • Inter-departmental • All levels of providers • Open forum • Case review of each SSI • PDSA Cycles
• Goal: • Reduction in SSI rates through:
•Culture change •Process change
• The Team • Surgeon Leader (Co-Chair) • Infection Control (Co-Chair) • Ortho Chair • Anesthesia Chair • Ob Gyn Chair / Nursing • Colorectal Surgery • Infectious Disease • OR Nursing Leadership • OR Coordinators • Quality Assurance • QI Core Measure
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An Overview of the Lutheran Quality ProgramThe Colon Bundle
Pre-Op
• Warming suits
• Antibiotic selection
• Antibiotic timing
• Pre-op CHG showers / Wipes
• Bowel prep
• Pre-op glycemic control
• Standardized orders
Peri-op
• Warming suits
• CHG pre-incision scrub
• Standard ABX selection • ABX re-dosing (> 3 hrs)
• ABX selection / dosing
guide poster in all ORs
• Intra-op glycemic control
• Standard wound closure
Post-op
• Warming suits
• Automatic Foley
discontinuation
• Standard post op wound
care
• Standard home wound
care orders
• Hyperglycemia Initiative
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Implementing a Colon SSI Reduction BundleColon SSI Rates
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Implementing a Colon SSI Reduction BundleColon SSI Rates (Risk Adjusted)
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Implementing a Colon SSI Reduction BundleCHG Skin Prep
• Home CHG baths or wipes
• Mandated CHG skin prep prior to incision
• Hair clipping
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An Overview of the Lutheran Quality ProgramActive Core Body Warming
• SSI rate hypothermic patient - 19% vs. 6%
• Increased cost and LOS
• Active patient warming is routine intra-op
• SCIP Core Measure
• Active warming in operative continuum advised
• Forced Warming Blanket
• Maintains core body temp
• Pre-, Peri-, Post-op
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An Overview of the Lutheran Quality ProgramAntibiotic Selection, Dosing, and Timing
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Implementing a Colon SSI Reduction BundleAntibiotic Dosing
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An Overview of the Lutheran Quality ProgramPeri-operative Glucose Control (Beyond the Sliding Scale)
• Insulin Protocol on the Surgical Services • Long and Intermediate acting insulin (weight-based)
• Correctional short acting insulin • Intra-op glucose management • Pre-op treatment of hyperglycemia or casecancellation
• Addition of Endocrine NP
• Peri-operative glycemic control • Glucose < 180
• Better Glycemic Control - Hospital-wide Goal
• Development of more in-depth protocol
• Accounts for body habitus
• Insulin naivety
• Type of feeding
• Insulin drips
• Hypoglycemia rate (glucose < 60) 1 – 2%
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An Overview of the Lutheran Quality ProgramPre-op Bowel Prep
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An Overview of the Lutheran Quality ProgramWound Protector and Standardized Fascial Closure
• Significant reduction in SSI
• Wound protector is placed
• Once laparotomy or mini-laparotomy is
performed
• Double gloving through out case
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Implementing a Colon SSI Reduction BundleIncreased Oxygenation
• Supplemental administration of oxygen during the perioperative period decreases the
incidence of wound infection.
• 500 patients undergoing colorectal randomized to receive 30% or 80% Fi02 during
colon surgery and for two hours afterward.
• Significantly higher PaO2 in the patients on 80% FiO2.
• Percent SSI in high O2 group 5.2%
• Percent SSI in low O2 group 11.2%
• P=0.01
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An Overview of the Lutheran Quality ProgramStandardized Fascial Closure
• Anastomosis “Time O ut”
• Re-draping
• New Mayo stand cover
• Clean light handles
• New patient drapes over the old
• Glove and gown change for entire team
• Instrument change
• Sterile closure tray opened
• Pulse irrigation of the wound
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An Overview of the Lutheran Quality ProgramBundle Compliance and Outcome
• Retrospective study of 559 patients who underwent major elective colorectal surgery. • 346 (61.9%) before bundle • 213 (38.1%) after bundle
• Implementation of the bundle was associated with: • Reduced superficial SSIs 19.3% vs 5.7% P < .001 • Postoperative sepsis 8.5% vs 2.4% P = .009
• No difference in deep SSIs, organ-space SSIs, wound disruption, LOS, 30-day readmission, or variable direct costs (VDC).
• Subgroup analysis showed superficial SSI associated with 35.5% increase in: • VDC $13,253 vs. $9,779 P = .001 • LOS 7.9 vs. 4.6 days (71.7%) P < .001
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Implementing a Colon SSI Reduction BundleOther Interventions – Hygiene and Reducing OR traffic
• Hand washing re-education
• Terminal OR cleaning
• Equipment redistribution in OR to optimize flow
• Restriction of passage through the ORs
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Implementing a Colon SSI Reduction Bundle Other Interventions - Hair Clipping Outside of the O R
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Implementing a Colon SSI Reduction BundleOther Interventions – Warm up jackets
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Implementing a Colon SSI Reduction BundleA Closer Look at 2014 SSIs – Urgency of Case
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Implementing a Colon SSI Reduction BundleA Closer Look at 2014 SSIs – Wound Classification
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Implementing a Colon SSI Reduction BundleA Closer Look at 2014 SSIs – Overall Bundle Compliance
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Implementing a Colon SSI Reduction BundleA Closer Look at 2014 SSIs – Compliance with Bundle Elements
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Implementing a Colon SSI Reduction BundleColon Bundle Compliance 2015
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Implementing a Colon SSI Reduction BundleColon SSI Prevention Bundle Refinements in 2014 - 2015
• Individual conversations w non-compliant surgeons
• CHG
• Wound protector
• CHG wipes in the pre-op area
• CHG bathing nurse driven protocol for the in patient
• Improved standardized wound closure
• Sterile tray
• Re-drape the patient
• Pulse Irrigation
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Implementing a Colon SSI Reduction BundleProcess Refinement, Data Reporting Data, and Work to Do
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