Fraser Health Fraser Health

Arthroplasty to Surgical Safety Arthroplasty to Surgical Safety an example of Spread an example of Spread

Martha GrypmaMartha GrypmaBest Practices Conference September 9Best Practices Conference September 9thth, 2008, 2008

Two measures in arthroplasty Two measures in arthroplasty collaborativecollaborative

Used Safer Health Care Now (SHCN) measures Used Safer Health Care Now (SHCN) measures for Prevention of Surgical site Infections (SSI) in for Prevention of Surgical site Infections (SSI) in Arthroplasty Collaborative (Hair Removal and Arthroplasty Collaborative (Hair Removal and Antibiotic Timing)Antibiotic Timing)

Blended approach between arthroplasy team Blended approach between arthroplasy team and SSI team at one siteand SSI team at one site

Val spreading learning from ArthroplastyVal spreading learning from Arthroplasty

PathwaysPathways

Clinical leadership groupsClinical leadership groups

Patient educationPatient education

Staff educationStaff education

Optimization Optimization

Martha taking lead on SSI initiative in FHMartha taking lead on SSI initiative in FH

Spread information and data we had from Spread information and data we had from arthroplasty collaborative arthroplasty collaborative

We had lots of room to improveWe had lots of room to improve

We needed to take SSI components forward and We needed to take SSI components forward and give it some focusgive it some focus

What Did Surrey MemorialWhat Did Surrey MemorialDo?Do?

Surgical Site Infection Rate and Antimicrobial Surgical Site Infection Rate and Antimicrobial Prophylaxis Timing for Total Joint Arthroplasty at Prophylaxis Timing for Total Joint Arthroplasty at

Surrey Memorial Hospital 1996Surrey Memorial Hospital 1996--20032003

1.4 1.4

3.9

0.6

1.6

1.0*0.8

0.0

0.5

1.0

1.5

2.0

2.5

3.0

3.5

4.0

4.5

1996/97 1997/98 1998/99 1999/2000 2000/01 2001/02 2002/03 2003/04

Fiscal year

Rate

of S

SI/1

00 T

otal

Joi

nt

Arth

ropl

astie

s

*

Baseline AuditBaseline Audit

Clippers in the ORClippers in the OR–– 0% compliance 0% compliance

Appropriate hair Appropriate hair removalremoval–– ????????

Antibiotic TimingAntibiotic Timing–– 34% compliance34% compliance

Reduce surgical site infection rates by 50% in Hip & Reduce surgical site infection rates by 50% in Hip & Knee Arthroplasty patients through:Knee Arthroplasty patients through:(1) optimal use of prophylactic antibiotics (1) optimal use of prophylactic antibiotics (2) appropriate hair removal (2) appropriate hair removal (3) maintain normothermia (3) maintain normothermia

Aim

Hair RemovalHair Removal

March 2006March 2006 -- clippers were not used forclippers were not used forhair removal in the OR hair removal in the OR

SuccessesSuccessesReplaced razors with sufficient number Replaced razors with sufficient number of clippersof clippersClippers now routinely used in hip and Clippers now routinely used in hip and knee arthroplasty when hair removal is knee arthroplasty when hair removal is required. required.

Hair RemovalHair Removal

PrePre--op teaching op teaching –– Do notDo not shave the operative shave the operative site for 7 days prior to surgery.site for 7 days prior to surgery.90%90% of hip Arthroplasty and of hip Arthroplasty and 79%79% of knee of knee Arthroplasty patients had no hair removal.Arthroplasty patients had no hair removal.

ChallengesChallengesPersonal preference of one surgeon to use a razor Personal preference of one surgeon to use a razor when hair removal is required. when hair removal is required.

Proportion of Total Hip & Knee Arthroplasty PatientsProportion of Total Hip & Knee Arthroplasty Patientswith Appropriate Hair Removal at SMHwith Appropriate Hair Removal at SMH

0.916666667

0.8

1

0.9090909090.923076923

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

110%

Feb2006

Mar2006

Apr2006

May2006

Jun2006

Jul2006

Aug2006

Sep2006

Oct2006

Nov2006

Dec2006

Jan2007

Feb2007

Mar2007

Apr2007

May2007

Jun2007

Jul2007

Aug2007

Sep2007

Month

Perc

enta

ge

(SHN - Surrey Memorial Hospital - SSI**)

SMH AIM: By October, 2006Achieve 95% or higher in implementing the three components of care for patients undergoing total joint replacement procedure

• Increase prophylactic antibiotic administration within 15 – 60 minutes ( 2 hours for Vancomycin ) , prior to surgical incision for hip and knee arthroplasty by October 2006.• Prophylactic antibiotic discontinued within 24 hours after surgery end time .• Achieve 100 % performance for pre - operative clipping of hair as close to incision time as possible ( eliminate use of razor shaving).

Note:* * see separate charts for Hip and Knee (from Mar - Oct/06).

• Aug /07 : n = 10

ANALYSIS

Updated: Oct.29, 2007

Target = 100%

Hip

Knee

Hip & Knee

4.0 Percentage of Surgical Patients with Appropriate Hair Removal

Prophylactic Antibiotic Prophylactic Antibiotic AdministrationAdministration

Baseline Baseline 34% of hip & knee arthroplasty patients 34% of hip & knee arthroplasty patients received prophylactic antibiotic administration on received prophylactic antibiotic administration on time.time.

SuccessesSuccessesPatient arrives in the OR with antibiotic ready for Patient arrives in the OR with antibiotic ready for infusion. infusion. OR recordOR record -- includes space to document the includes space to document the time the antibiotic is started. time the antibiotic is started.

Prophylactic Antibiotic Prophylactic Antibiotic AdministrationAdministration

ChallengesChallengesPrePre--operative prophylactic antibiotic operative prophylactic antibiotic not not alwaysalwaysordered.ordered.

WhoWho should consistently start the infusion??should consistently start the infusion??

66.7% of the cases requiring 66.7% of the cases requiring Vancomycin Vancomycin did did not meet the recommended timing for prenot meet the recommended timing for pre--op op antibiotic administration. antibiotic administration.

Proportion of Total Hip & Knee Arthroplasty Patients Proportion of Total Hip & Knee Arthroplasty Patients Receiving Antimicrobial Prophylaxis on Time at SMHReceiving Antimicrobial Prophylaxis on Time at SMH

1.0 Percentage of Surgical Patients with Timely Prophylactic Antibiotic Administration

90.00%90%

80%

100%

90%

100%

77.78%80%

83.33%

88.89%

46.67%

75%

91.67%

77.78%

88.89%

90.91%92.31%

21.43%

100%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

110%

Feb2006

Mar2006

Apr2006

May2006

Jun2006

Jul2006

Aug2006

Sep2006

Oct2006

Nov2006

Dec2006

Jan2007

Feb2007

Mar2007

April2007

May2007

June2007

Jul2007

Aug2007

Sep2007

Month

Perc

enta

ge

(SHN - Surrey Memorial Hospital - SSI**)

SMH AIM: By October, 2006Achieve 95% or higher in implementing the three components of care for patients undergoing total joint replacement procedure • Increase prophylactic antibiotic administration within 15 – 60 minutes (2 hours for Vancomycin), prior to surgical incision for hip and knee arthroplasty by October 2006.• Prophylactic antibiotic discontinued within 24 hours after surgery end time.• Achieve 100% performance for pre-operative clipping of hair as close to incision time as possible (eliminate use of razor shaving).

Note:* * see separate charts for Hip and Knee (from Mar - Oct/06).• Nov/06: n=10• Dec/06 - Jan/07: n=1• Feb - Mar/07: n=10• Apr/07: n=9• May - Aug07: n=10

ANALYSIS

Updated: Oct.29, 2007

Target = 95%

Hip

Knee

Hip & Knee

Antibiotic DiscontinuationAntibiotic Discontinuation

24 hour24 hour discontinuation postdiscontinuation post--op was not in op was not in place. place. Care Path for hip and knee Arthroplasty Care Path for hip and knee Arthroplasty --discontinuation discontinuation 48 hours post48 hours post--op.op.Care Path revised to reflect best practice are Care Path revised to reflect best practice are in progress.in progress.PostPost--op orders reflect discontinuation 24 op orders reflect discontinuation 24 hours posthours post--opop

Antibiotic DiscontinuationAntibiotic Discontinuation

0.9

0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

0.9

1

May2006

Jun2006

Jul2006

Aug2006

Sep2006

Oct2006

Nov2006

Dec2006

Jan2007

Feb2007

Mar2007

Apr2007

May2007

June2007

Jul2007

Aug2007

Sep2007

Month

Perc

enta

ge

(SHN - Surrey Memorial Hospital - SSI**)

SMH AIM: By October, 2006Achieve 95% or higher in implementing the three components of care for patients undergoing total joint replacement procedure • Increase prophylactic antibiotic administration within 15 – 60 minutes (2 hours for Vancomycin), prior to surgical incision for hip and knee arthroplasty by October 2006.• Prophylactic antibiotic discontinued within 24 hours after surgery end time.• Achieve 100% performance for pre-operative clipping of hair as close to incision time as possible (eliminate use of razor shaving).

Note:* * see separate charts for Hip and Knee (from Mar - Oct/06).• Aug/07: n=10

ANALYSIS

Updated: Oct.29, 2007

Target = 95%

Hip Knee

Hip & Knee

Baseline(Hip: n=2, Knee: n=9)

2.0 Percentage of Surgical Patients with Appropriate Prophylactic Antibiotic Discontinuation

NormothermiaNormothermia

GoalGoal -- maintain 36maintain 36--3838°°C. C. AuditAudit -- 30 colorectal 30 colorectal surgical patients.surgical patients.86%86% -- temperature temperature 36.0 or greater 36.0 or greater immediately postimmediately post--op. op. Fluid and/or hot air Fluid and/or hot air warmer used in warmer used in 25/3025/30 procedures.procedures.

Spread within Spread within Surrey Memorial HospitalSurrey Memorial Hospital

ClippersClippers –– first choice for hair removal in all the first choice for hair removal in all the operating theatres. operating theatres.

CommunicationCommunication –– all ORs, Surgical and Maternity all ORs, Surgical and Maternity units regarding SSI bundle. units regarding SSI bundle.

Surgical Safety CollaborativeSurgical Safety Collaborative

Spread outside of SMH Spread outside of SMH ––What staff said to usWhat staff said to us

OR nurses complained about the number OR nurses complained about the number of of ““projectsprojects”” that tapped into same staff, that tapped into same staff, doctor and processes in the roomdoctor and processes in the room

Other Other ““safetysafety”” initiatives initiatives

Site MarkingSite MarkingSurgical Pause or Time OutSurgical Pause or Time OutPrevention of Surgical Site InfectionPrevention of Surgical Site Infection-- Hair Hair Removal, Antibiotic timing preRemoval, Antibiotic timing pre––op, Antibiotic op, Antibiotic discontinuation, Normothermia discontinuation, Normothermia Crew Resource Management (CRM)Crew Resource Management (CRM)Surgical Outcomes Work (NSQIP)Surgical Outcomes Work (NSQIP)Emerging initiatives Emerging initiatives ––Surgical Apgar, checklists, Surgical Apgar, checklists, Medication Reconciliation Medication Reconciliation

Why another collaborativeWhy another collaborative

Builds willBuilds will-- it requires learning and sharingit requires learning and sharingShares ideasShares ideas-- we work better togetherwe work better togetherMeasurementMeasurement--keeps our eyes on the keeps our eyes on the targets and lets us know what is workingtargets and lets us know what is workingChange Change -- ideas tested in small ways then ideas tested in small ways then spread got us to end goals quicker than spread got us to end goals quicker than project management approach project management approach

Surgical Safety Collaborative Surgical Safety Collaborative (SSC) Aims(SSC) Aims

Spread the SCHN improvement learning from Spread the SCHN improvement learning from Surrey Hospital experience with the SSI bundleSurrey Hospital experience with the SSI bundle

Hair removal, antibiotic timing/discontinuation, Hair removal, antibiotic timing/discontinuation, normothermia.normothermia.

Follow up on previous safety initiativeFollow up on previous safety initiativeevaluation of site marking and surgical pauseevaluation of site marking and surgical pause

Create a learning community of practiceCreate a learning community of practicefor sharing of ongoing innovations such as CRM, for sharing of ongoing innovations such as CRM, surgical surgical apgarapgar and checklists, NSQIP and checklists, NSQIP

A little comment on NSQIPA little comment on NSQIP……National Surgical Quality Improvement ProjectNational Surgical Quality Improvement Project

ProspectiveProspectiveStandardized Standardized definitionsdefinitionstrained nurse trained nurse reviewersreviewersinterraterinterrater reliabilityreliabilitydefined endpointsdefined endpoints30 day mortality30 day mortality30 day morbidity30 day morbidity

RISK ADJUSTMENTRISK ADJUSTMENT

An example of what NSQIP has An example of what NSQIP has revealedrevealed……

High outlier hospitals have problems with High outlier hospitals have problems with efficiency and coordination in the ORefficiency and coordination in the ORResulting in longer OR durationResulting in longer OR durationOR efficiency and surgeon efficiency now OR efficiency and surgeon efficiency now looked at more closely as linkages to higher looked at more closely as linkages to higher infection rates in places with low efficiencyinfection rates in places with low efficiencyMay benefit from CRM trainingMay benefit from CRM training

TeamsTeams

All FH operating rooms represented All FH operating rooms represented Some examples of our improvements over the Some examples of our improvements over the last year last year –––– Antibiotic timing has improvedAntibiotic timing has improved–– Patients are monitored closely for normothermia & Patients are monitored closely for normothermia &

temps in PACU has improvedtemps in PACU has improved–– Use of clippers has increased, education in preUse of clippers has increased, education in pre--

admission regarding preadmission regarding pre--shavingshaving–– Establishment of relationship with purchasing teamEstablishment of relationship with purchasing team

Example of Progress Presented for 3Example of Progress Presented for 3rdrd Learning Learning Session Session -- NormothermiaNormothermia

(all teams)(all teams)

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Baseline Nov Dec Jan Feb March April

Blanket/Warmer Temp PACU

Fraser Health - cumulative spot checks (baseline - July 08)

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Baseline Oct Nov Dec Jan Feb Mar Apr May Jun Jul

Antibiotic Timing Skin prep - Hair removal

Examples of what has been Examples of what has been achievedachieved

Multiple team Multiple team PDSAsPDSAs and improvementsand improvementsTools for teams, antibiotic guideline , skin Tools for teams, antibiotic guideline , skin prep solution info sheet, standardization of prep solution info sheet, standardization of OR documentation recordOR documentation record

Comparison of Characteristics of Comparison of Characteristics of Antimicrobial AgentsAntimicrobial Agents 1,2 1,2

LS#3 Surgical Safety Collaborative Page 1 of 1 10 J 2008

Antimicrobial Agent Excellent to Good Effectiveness

Rapidity of Action/

Residual Effect

Precautions FH Product

Alcohol Provide a rapid and significant reduction in skin microbial counts

Gram-positive bacteria Gram-negative bacteria Fungi Viruses M. tuberculosis

1 minute/None

• Volatile • Drying to the skin • Use with agents that

promote residual antimicrobial activity

• 70% alcohol/2% CHG • 70% alcohol/0.5% CHG • 74% alcohol/7% PI • 70% isopropyl alcohol

Iodine Provides rapid reductions in skin microbial counts. Should be removed after 2-3 minutes to prevent skin irritation. Iodophors Less likely to cause skin irritation and do not need to be removed.

Gram-positive bacteria Gram-negative bacteria Fungi Viruses M. tuberculosis

2 minutes/ Minimal

Patients allergic to iodine

may react to iodophors Can cause skin irritation Rapidly neutralized by

organic materials such as blood or sputum

Residual effect may be increased when combined with alcohols

• 70% poviodine • 0.5% tincture iodine • 74% alcohol/7%PI (e.g.Duraprep)

Chlorhexidine Does not provide as rapid a reduction in skin microbial counts as alcohol, but provides a longer residual effect (5-6 hours). This effect remains active in the presence of blood and other organic material.

Gram-positive bacteria Gram-negative bacteria Viruses

Rapid; as little as 15 seconds/ 6 hours

• Ototoxicity • Ocular toxicity

• 70% alcohol/2% CHG (e.g. Chloraprep) • 70% alcohol/0.5% CGH

References 1. Health Canada. 1998. Hand Washing, Cleaning,Disinfection and Sterilization in Health Care. Can Communic Dis Report Vol 24S8.

2. Centers for Disease Control and Prevention. 1999. Guideline for prevention of surgical site infections. Infect Control Hosp Epidemiol 20(4):247–78.

What worked for usWhat worked for us

Leadership commitmentLeadership commitment

A collaborative model/community of practiceA collaborative model/community of practice

Quality improvement tools that have meaning Quality improvement tools that have meaning to frontline staffto frontline staff

Highlights of the SSCHighlights of the SSC

The keynotesThe keynotesAwesome presentationsAwesome presentations-- great motivator for teams, they learned a great motivator for teams, they learned a lot from our keynoteslot from our keynotes--Keith Keith MartinsenMartinsen-- safety management modelsafety management model-- now working on now working on training DVD for CRM (TRM)training DVD for CRM (TRM)Dr. Dr. LaFlammeLaFlamme-- NormothermiaNormothermiaDr. Skip CampbellDr. Skip Campbell-- NSQIPNSQIP-- Dr. Anisha Lakhani Dr. Anisha Lakhani -- Antibiotic Antibiotic prophylaxis guidelinesprophylaxis guidelinesPhilosopher cafPhilosopher cafééssBuilding a strong facultyBuilding a strong faculty-- IC, Products, Operational Leadership, MD, IC, Products, Operational Leadership, MD, Clinical experts, QIClinical experts, QIDedicated coordinatorDedicated coordinator-- keeps teams on track, data support, logistics keeps teams on track, data support, logistics ++++++++Story boards and team sharingStory boards and team sharing--Networking time and team meetings Networking time and team meetings

Where nextWhere nextLearning session #4 Oct 14Learning session #4 Oct 14-- focus on social marketingfocus on social marketingSecured sustainable funding for SSC endeavors to move Secured sustainable funding for SSC endeavors to move forwardforwardMeasurement plan for sustaining and spreading current Measurement plan for sustaining and spreading current improvementsimprovementsPlans for improvement on new innovationsPlans for improvement on new innovations-- APGAR and APGAR and checklistchecklistTRM full pilot at one siteTRM full pilot at one siteMake NSQIP data regular part of operational meetings, Make NSQIP data regular part of operational meetings, staff meetings, so use it to create culture of improving staff meetings, so use it to create culture of improving and always striving to do better for patients. and always striving to do better for patients.

Thank youThank you