oklahoma foundation for medical quality performance improvement for the surgeon: sipp and scpp...

Oklahoma Foundation for Medical Quality

Performance Improvement for the Performance Improvement for the Surgeon: SIPP and SCPPSurgeon: SIPP and SCPP

Twelfth G. Rainey Williams Surgical Symposium

September 29th, 2005



Surgical Infection Prevention Project National program funded by CMS Can be used as JCAHO PI project Oklahoma collaborative project



Why SIPP?


Public Health Importance

SSI occurs in 2-5% of extra abdominal surgeries and up to 20% of intra-abdominal surgeries

SSI patients are

• 60% more likely to spend time in the ICU

• 5x more likely to be re-admitted

• 2x the incidence of mortality


Impact of SSI’sImpact of SSI’sCase Control* Study of 255 PairsCase Control* Study of 255 Pairs

Infected Uninfected

Mortality 7.8% 3.5%

ICU admission 29% 18%

L.O.S. 11d 6d

Median direct cost $7531$3844

Readmission 41% 7%

Kirkland. Infect Control Hosp Epidemiol 1999; 20: 725

* matched for procedure, NNIS index, age


Most Common Hospital-Most Common Hospital-acquired Infections, 1995acquired Infections, 1995

30%

18%16%

15%

21%Urinary tract

infections

Bloodstream infectionsSurgical site

infections

Pneumonia

Other


Estimated Annual Impact of Estimated Annual Impact of SSIs After Specific ProceduresSSIs After Specific Procedures

CABG

Colorectal

Hip Replace

Knee Replace

# Procedures

383,000

250,000

293,000

324,000

# SSIs

14,975 15,075 4,109 3,726

# Deaths

11,107 11,500 3,809 648

Total Costs (in millions)

$84 $127 $196 $63


SSI SurveillanceSSI SurveillanceNNIS Risk Index

Patient-Specific Risk Score

0-3 Points Possible

Patient Characteristic Points

Wound class III or IV 1 point

ASA score 3, 4, or 5 1 point

Duration of surgery > cutpoint 1 point


SSI Rates* by Surgery Type SSI Rates* by Surgery Type and NNIS Risk Scoreand NNIS Risk Score

NNIS Risk Score

Operation

Duration Cutpoint (hours)

0

1

2

3

Abd Hyst 2 1.5 2.5 6.1 †

Total knee 2 0.9 1.2 2.0 †

Small bowel surgery 3 5.6 7.5 9.8 14.8

CABG (chest and leg) 5 0.7 3.5 5.8 17.5

*Infections per 100 procedures*Infections per 100 procedures

†Risk index categories 2 and 3 combined

Oklahoma Foundation for Medical Quality SSI Risk FactorsSSI Risk Factors

Age Obesity Diabetes Malnutrition Prolonged pre-

operative stay Infection at a

remote site

Shaving site Duration of surgery Surgical technique Presence of drains Inappropriate use of

antimicrobial prophylaxis

Newly Identified:

Hyperglycemia, hypothermia, and tissue hypoxemia


Surgical Procedures of InterestNational Surgical Infection Prevention Project

Cardiac Coronary Artery Bypass Graft (CABG) Colon Hip & Knee Arthroplasty Hysterectomy (abdominal and vaginal) Vascular Surgery:

• Aneurysm repair• Thromboendarterectomy• Vein Bypass

These procedures are being evaluated in the Medicare project because there is no controversy over the use of antibiotics for these operations. This does not imply that antibiotic prophylaxis should not be used for other procedures.


Quality IndicatorsQuality IndicatorsNational Surgical Infection Prevention Project

Quality Indicator #1

• Proportion of patients who receive antibiotics within 1 hour before surgical incision

Because of the longer required infusion time, vancomycin, when indicated for beta-lactam allergy, may be started within 2 hours before the incision.


Impact of Timing of Antibiotic Impact of Timing of Antibiotic ProphylaxisProphylaxis

Antibiotic Timing SSI Incidence

Relative Risk

P value

2-24 hours preop 3.8% -- --

< 2 hours preop 0.6% 0.15 <0.001

3 hours postop 1.4% 0.37 0.11

3-24 hours postop 3.3% 0.86 0.8

Classen DC, et al. Classen DC, et al. N Engl J MedN Engl J Med. 1992.. 1992.


0

1

2

3

4

≤-3 -2 -1 0 1 2 3 4 ≥5

Classen, et al. N Engl J Med. 1992;328:281.

Perioperative AntibioticsPerioperative AntibioticsTiming of AdministrationTiming of Administration

Infe

cti

on

s (

%)

Infe

cti

on

s (

%)

Hours From IncisionHours From Incision

14/36914/369

5/6995/6995/10095/1009

2/1802/1801/811/81

1/411/411/471/47

15/44115/441


Prophylactic Antibiotics TimingProphylactic Antibiotics TimingCefoxitinCefoxitin

Incision2 hours3 hours

34

11

7

99

22

11

On Call Induction

Serum Levels

DiPiro JT, et al. Arch Surg. 1985;120:829-832.

Blood levels at the time of the incision are important to reduce infection!


Dose of Antibiotic for Dose of Antibiotic for ProphylaxisProphylaxis

Always give at least a full therapeutic dose of antibiotic

Consider the upper range of doses for large patients and/or long operations

Consider repeating doses for long operations




• Proportion of patients who receive prophylactic antibiotics consistent with current recommendations


Appropriate AntibioticsAppropriate AntibioticsNational Surgical Infection Prevention Project

Cardiac and vascular surgery• cefazolin, cefuroxime, cefamandole• (vancomycin only if documented beta-

lactam allergy)

Hip and knee arthroplasty• cefazolin, cefuroxime• (vancomycin only if documented beta-

lactam allergy)



Hysterectomy• cefazolin, cefotetan, cefoxitin, or

cefuroxime• (fluoroquinolone + clindamycin if

documented beta-lactam allergy)



Colorectal surgery• Oral (after effective mechanical bowel prep)

administered for 18 hours preop– neomycin sulfate + erythromycin base, or– neomycin sulfate + metronidazole

• Parenteral– cefoxitin, cefotetan, cefmetazole, or cefazolin +

metronidazole– (fluoroquinolone + clindamycin if documented beta-

lactam allergy)


Antibiotic Recommendation Sources

American Society of Health System Pharmacists

Infectious Diseases Society of America

The Hospital Infection Control Practices Advisory Committee

Medical Letter

Surgical Infection Society

Sanford Guide to Antimicrobial Therapy 2001




• Proportion of patients whose prophylactic antibiotics were discontinued within 24 hours of surgery end time


Duration of ProphylaxisDuration of ProphylaxisGastrointestinalGastrointestinal

Author Drug Duration Infection

Strachan 1977 cefazolin 1 dose 3%(biliary) 5 days 6%

placebo 17%

Stone 1979 cefamandole 3 doses 0(mixed) 5 days 3%

cephaloridine 5 days 4%

Hall 1989 moxalactam 1 dose 5%(mixed) 2 days 6%


Duration of ProphylaxisDuration of ProphylaxisCardiacCardiac


Conte 1972 cephalothin 1 dose 10%4 days 9%

Goldmann 1977 cephalothin 2 days 4%6 days 6%

Austin 1980 cephalothin 2 doses 11%3 days 9%

Geroulanos 1986 cefuroxime 2 days 1.1%cefazolin 4 days 2.5%


Duration of ProphylaxisDuration of ProphylaxisJoint Replacement


Pollard 1979 cephaloridine 12 hours 1.4%(hips) flucloxacillin 14 days 1.3%

Heydemann 1986 cefazolin 1 dose 0(hips and knees) 24 hours 1%

48 hours 0 7 days 1.5%


Impact of Prolonged Antibiotic Impact of Prolonged Antibiotic ProphylaxisProphylaxis

2,641 CABG patients• Grp 1 - < 48 hours of antibiotics• Grp 2 - > 48 hours of antibiotics

SSI Rates• Grp 1 - 8.7% (131/1502)• Grp 2 - 8.8 % (100/1139)

Antibiotic resistant pathogen - Grp 2• Odds Ratio 1.6 (95% CI: 1.1-2.6)

Harbarth S, et al. Circulation. 2000.


Antibiotic ProphylaxisAntibiotic ProphylaxisDuration

In summary -

• Most studies have confirmed efficacy of 12 hrs of prophylactic antibiotics

• Many studies have shown efficacy of a single dose

• Whenever compared, the shorter course has been as effective as the longer course and results in less antibiotic resistance

Oklahoma Foundation for Medical Quality Surgical Infection PreventionSurgical Infection Prevention

Besides appropriate antibiotic selection, what else reduces infection?


HICPAC - SSI Prevention HICPAC - SSI Prevention Guidelines - 1999Guidelines - 1999

Category 1

No prior infections 15 air changes/hr in O.R.Do not shave in advance1 Keep O.R. doors closed Control glucose in D.M. pts Use sterile instrumentsStop tobacco use Wear a mask*Shower with antiseptic soap Cover hair*Prep skin with approp. agent Wear sterile gloves*Surgeon’s nails short Gentle tissue handlingSurgeons scrub hands DPC for heavily contaminated Exclude infected surgeons woundsGive prophylactic antibiotics Closed suction drains (when

used)Pos pressure ventilation in O.R. Sterile dressing x 24-48 hr

SSI surveillance with feedback to surgeons

1Every published study of razor shaving has shown increased infection rates!


Enhanced Perioperative Enhanced Perioperative Glucose Control in DiabeticsGlucose Control in Diabetics

2,467 diabetic patients undergoing cardiac surgery• Control group - subcutaneous insulin• Treatment group - IV insulin infusion

Results• Controls - 2.0% SSI rate (19/968)• Treatment- 0.8% SSI rate (12/1499), P=0.01

Furnary AP, et al. Ann Thorac Surg. 2000.

Oklahoma Foundation for Medical Quality Perioperative Glucose ControlPerioperative Glucose Control

1,000 cardiothoracic surgery patients Diabetics and non-diabetics with hyperglycemia

Patients with a blood sugar > 300 mg/dL during or within 48 hours of surgery had more than 3X the likelihood of a wound infection!

Latham R, et al. Infect Control Hosp Epidemiol. 2001.

Oklahoma Foundation for Medical Quality Temperature ControlTemperature Control

200 colorectal surgery patients• control - routine intraoperative thermal care

(mean temp 34.7°C)• treatment - active warming (mean temp on

arrival to recovery 36.6°C)

Results• control - 19% SSI (18/96)• treatment - 6% SSI (6/104), P=0.009

Kurz A, et al. N Engl J Med. 1996.

Also: Melling AC, et al. Lancet. 2001. (preop warming)


Supplemental Perioperative OSupplemental Perioperative O22

500 colorectal surgery patients• control - 30% FiO2 intra- and post-op*

• treatment - 80% FiO2 intra- and post-op*

Results• control - 11.2% SSI (28/250)• treatment - 5.2% SSI (13/250), P=0.01

*2 hours postoperatively

Greif R, et al. N Engl J Med. 2000.


Reducing Surgical InfectionsReducing Surgical InfectionsSummary

In addition to usual infection control:• Appropriate antibiotic treatment

– timing, selection, duration (intra-op dosing for long cases or excess blood loss)

• Avoid shaving and other HICPAC recommendations

• Blood glucose control (diabetics and non-diabetics)

• Temperature control (goal 37°C)• Supplemental O2

Oklahoma Foundation for Medical Quality Website Resource

www.surgicalinfectionprevention.org



Surgical Complication Prevention Project New project being piloted now More broad than SIPP Will probably become routine PPI project



What does this mean for you? It will improve your patient outcomes It may satisfy MOC requirements It may become your hospital’s PPI

project Surgeons should remain quality

leaders

oklahoma foundation for medical quality performance improvement for the surgeon: sipp and scpp...

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