Arizona Surgical Infection Prevention (SIP) Collaborative

Summary
Problem Statement
Mission
Performance Measures
Goals
Methods
Expectations
References

Summary
The purpose of the Arizona Surgical Infection Prevention (SIP) Collaborative is to improve the quality of care delivered to patients during surgery in a cost-effective manner through system redesign using proven, evidence-based practices. The goals, as reflected in process measures, are that 100 percent of eligible patient populations receive appropriate and timely prophylactic antibiotics. Hospitals are also strongly encouraged to select additional prevention-related interventions related to normothermia, glucose control, oxygenation, hair removal, and other infection-prevention procedures to improve redesign of their systems of care.

Problem Statement
Americans rely on their health care system for the maintenance and improvement of health, which often involves care in the hospital setting. Although most patients believe that the American health care system provides the highest quality and safest care in the world, it is estimated that four out of every one hundred hospitalized patients in the United States suffer a serious adverse event, many of which are avoidable. In the Institute of Medicine report, To Err is Human, it is estimated that between 44,000 and 98,000 deaths per year result from adverse events.(1) In comparison, there are approximately 45,000 deaths yearly from auto accidents.

Sixty-nine percent of adverse events and deaths in health care are due to an error in management and, thus, are potentially preventable. Dr. Lucian Leape and colleagues have described these types of errors, which include diagnostic failures, treatment errors, errors in prevention, and others including communication failure and equipment failure. (2) Some of these errors lead to perioperative infections––a major cause of patient injury, mortality, and health care cost. An estimated 2.6 percent of nearly 30 million operations are complicated by surgical site infections (SSIs) each year.

Established in 1970, the Centers for Disease Control and Prevention’s (CDC’s) National Nosocomial Infections Surveillance (NNIS) system monitors reported trends in nosocomial infections in U.S. acute-care hospitals. According to the NNIS system reports, SSIs are the third most frequently reported nosocomial infection, accounting for 14 percent to 16 percent of all nosocomial infections among hospitalized patients. (3) Surgical site infections are a common complication of care, occurring in 2 percent to 5 percent of patients after clean extra-abdominal operations (e.g., thoracic and orthopedic operations) and in up to 20 percent of patients undergoing intra-abdominal procedures.(4–9) Among surgical patients, SSIs were the most common nosocomial infection, accounting for 38 percent of all such infections. When surgical patients with nosocomial SSI died, 77 percent of the deaths were reported as related to the infection, and the majority (93 percent) were serious infections involving organs or spaces accessed during the operation. (10) Cruse estimated that an SSI increased a patient’s hospital stay by approximately ten days and cost an additional $2,000 in 1980. (11,12) There are more recent studies, including a 1992 analysis by Martone, which corroborate an increase in length of stay and cost (7.3 additional postoperative hospital days and $3,152 in extra charges) in patients with SSIs.(13–15) If a hospital with an annual surgical volume of 10,000 operations could reduce their 300 SSIs by half, this would result in an average annual cost savings of approximately $450,000, based on 1992 cost estimates. Deep SSIs involving organs or spaces are associated with even greater increases in hospital stays and costs. (16,17)

An estimated 40 percent to 60 percent of SSIs are preventable with appropriate use of prophylactic antibiotics.10,18–20 Overuse, underuse, improper timing, and misuse of antibiotics occurs in 25 percent to 50 percent of operations.21–24 A large number of hospitalized patients develop infections caused by Clostridium difficile, and 16 percent of this type of infection in surgical patients can be attributed to inappropriate prophylaxis use alone.25 Inappropriate use of broad spectrum antibiotics, or prolonged courses of prophylactic antibiotics, puts all patients at even greater health risks due to the development of antibiotic-resistant pathogens.

In addition to the proper use of prophylactic antibiotics and good surgical technique, other factors under the control of the operative team have been demonstrated to significantly affect the risk of SSI. (10) These other factors include preventing hypothermia during the procedure, (26) maintaining high levels of inspired oxygen, (27) controlling serum glucose within certain limits, (28–30) and avoiding shaving the operative site. (31–35) All of these preventive measures provide opportunities for improvement in most hospitals.

Although the primary focus of the Collaborative work is SSIs, infections in patients undergoing surgery are not limited to those that involve the surgical site. Other types of infections occurring in patients undergoing surgery include, but are not limited to, infections of centrally inserted venous access lines for perioperative monitoring, urinary tract infections, and pneumonia.

Effective surgical infection prevention and harm reduction therefore require redesigning systems with safety in mind. (36) The fundamental law of improvement is this: every system is perfectly designed to achieve exactly the results it gets. In order to attain a new level of performance in safety, there must be a new system. This applies to all forms of performance—such as selection, timing, and duration of antimicrobial prophylaxis; thermoregulation; oxygen tension; glucose control; hair removal; and other basic prevention strategies. Some health care organizations have succeeded in creating new and safer systems for SSIs. (37) Major opportunities exist to reduce the incidence of surgical infections, create safer care for patients requiring surgery, create a more satisfactory work environment for health care workers, reduce costs, and improve efficiency.

Reducing surgical infections while minimizing antibiotic resistance remains a challenge to many health care institutions. Health care providers are faced with the additional challenge of trying to integrate new evidence-based infection prevention strategies, such as perioperative glycemic control, into practice. Enlightened management teams, regulatory agencies, health plan providers and purchasers, and medical associations need to provide the support required to create a culture of patient safety in our health care systems. With this support, informed, activated hospital teams can be empowered to make key changes to their subsystems (e.g., surgical units). Hospital teams need to incorporate safety considerations into their everyday work.

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Mission
The mission during this Collaborative is to achieve a breakthrough improvement in surgical infection prevention. The primary emphasis of this Collaborative is to create systems of care that dramatically improve the prevention of surgical infections. The Collaborative will take a preventive approach, which includes, but is not limited to, preventing SSIs. Hospitals will prevent infections by implementing a system-wide model of care, which focuses on assuring the safe delivery of care on a day-to-day basis for patients undergoing surgery.38 The mission encourages hospitals to redesign systems within a safety culture.

A safety culture can be defined as “the product of individual and group values, attitudes, competencies, and patterns of behavior that determine the commitment to, and style and proficiency of, an organization’s health and safety programs.”  (38)  Hospitals with a positive safety culture are characterized by communications founded on mutual trust, by shared perceptions of the importance of safety, and by confidence in the efficacy of preventive measures.

HSAG and the Collaborative faculty will help each hospital achieve its goal and this mission by providing support, sharing scientific knowledge, and by teaching the application of methods for organizational change.

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Performance Measures

Proportion of patients who received prophylactic antibiotics within one hour before surgical incision.

Studies indicate that antimicrobial prophylaxis is most effective when provided prior to the initial incision. Risk of infection increases when prophylaxis is given too early (more than two hours prior to initial incision) or too late (after initial incision). Many experts believe that the optimal time for administration is 30 to 60 minutes prior to incision, or within two hours before incision if vancomycin is required for prophylaxis.

Proportion of patients given a prophylactic antibiotic consistent with current recommendations.

Proportion of patients who received prophylactic antibiotics whose antibiotics were discontinued within 24 hours after surgery.

Studies have shown that a brief course of antimicrobial prophylaxis, when initiated shortly before the first incision, is as effective as longer courses. Additionally, prolonged antibiotic use has been associated with super infection with Clostridium difficile and may impact the development of resistant strains of bacteria. Some experts recommend to maintain a therapeutic level only through wound closure, and that a single dose is adequate unless the surgery is greater than four hours, major blood loss occurs, or an antimicrobial with a short half-life is used.

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Goals

The main goals of the Arizona SIP Collaborative are:

• One hundred percent of patients will have antibiotic prophylaxis initiated within one hour prior to incision.

• One hundred percent of patients will be given prophylactic antibiotics consistent with published guidelines.

• One hundred percent of patients given prophylactic antibiotics will have those antibiotics discontinued within 24 hours after surgery.

See “Measurement Strategy” section for exceptions, which include patients who: are receiving vancomycin, have tourniquets, or are undergoing C-sections.

For a list of measures related to these goals, see the “Measurement Strategies” section. Most teams will have additional goals related to other surgical infection prevention strategies.

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Methods

Each hospital is expected to develop a statement on what the team expects to accomplish during the Collaborative (an aim statement) that includes specific goals relating to preventing surgical infections. Hospitals should begin by working initially within a specific surgical population (pilot population), or with one or two surgeons (clinical champions) and anesthesiologists (also clinical champions). The ultimate goal is to spread the improvements to other populations and throughout the entire system. Hospitals should select initial pilot populations based on internal infection data and/or based on the following suggested surgical procedures: coronary artery bypass grafts (CABG), cardiac operations, colon operations, hip and knee arthroplasty, abdominal and vaginal hysterectomy, or selected vascular surgery procedures. To facilitate learning during the Collaborative, hospitals should try to identify a pilot population that is expected to result in at least 30 surgeries of procedure-of-selected-interest per month.

Both process and outcome measurement strategies will be used to assess organizational progress toward achieving Collaborative goals. Hospitals will learn an improvement strategy that includes breakthrough goals and a method to develop, test, and implement changes in their systems. Hospitals will be expected to collect well-defined data that relate to their aim at least monthly, and to plot these data over time for the duration of the Collaborative. An annotated time series or run chart will be used to assess the impact of changes.

The Collaborative faculty will aid hospitals in capitalizing on the learning and improvement from the focused project by simultaneously coaching senior leaders in hospitals to develop a system for spreading improvement to other surgical populations, sites, units, or surgical staff.

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Expectations

HSAG and the Collaborative faculty will:

• provide information on subject matter, application of that subject matter, and methods for process improvement, both during and between Learning Sessions

• offer coaching to teams

• provide an electronic mailing list and other communication venues for shared learning

• assess team progress and provide feedback to teams monthly

• plan and implement the four face-to-face meetings (three Learning Sessions and an Outcomes Congress)

• maintain and safeguard the confidentiality of privileged data or information—whether written, photographed, or electronically recorded, and whether generated or acquired by the team—which can be used to identify an individual patient, practitioner, hospital, facility, health plan, or patient population

Hospitals are expected to:

• perform pre-work activities as outlined in Section II of the handbook

• connect the goals of the Collaborative work to a strategic initiative in the hospital

• provide a senior leader to sponsor and actively support the team

• provide the resources to support the team, including resources necessary for learning sessions and staff time to devote to this effort

• participate in each Learning Session (participation by all core team members is highly recommended, and participation in the Outcomes Congress that concludes the Collaborative is desirable)

• identify the performance measures that the team is going to target, including the required performance measures related to appropriate antibiotic prophylaxis

• plan, design, and implement plan-do-study-act (PDSA) improvement cycles to meet the targeted performance measures

• submit monthly reports to the team’s senior leader and HSAG, identifying progress and PDSA cycles implemented

•  create storyboards for presentation at each Learning Session

• share information with the Collaborative, including details of changes made and data to support these changes, both during and between Learning Sessions

• maintain and safeguard the confidentiality of privileged data or information—whether written, photographed, or electronically recorded, and whether generated or acquired by the team—which can be used to identify an individual patient, practitioner, hospital, facility, health plan, or patient population

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References

1. Institute of Medicine. (1999). To Err is Human. Washington, D.C.: The National Academy Press.

2. Leape LL, Lawthers AG, Brennan TA, Johnson WG. (1993). Preventing medical injury. Quality Review Bulletin, 19, 144–9.

3. Emori TG, Gaynes RP. (1993). An overview of nosocomial infections, including the role of the microbiology laboratory. Clin Microbiol Rev, 6(4), 428–42.

4. Delgado-Rodriguez M, Sillero-Arenas M, Medina-Cuadros M, Martinez-Gallego G. (1997). Nosocomial infections in surgical patients: Comparison of two measures of intrinsic patient risk. Infect Control Hosp Epidemiol, 18, 19–23.

5. Horan TC, Culver DH, Gaynes RP, Jarvis WR, Edwards JR, Reid CR. (1993). Nosocomial infections in surgical patients in the United States, January 1986–June 1992. National Nosocomial Infections Surveillance (NNIS) System. Infect Control Hosp Epidemiol, 14, 73–80.

6. Horan TC, Gaynes RP, Martone WJ, Jarvis WR, Emori TG. (1992). CDC definitions of nosocomial surgical site infections, 1992: A modification of CDC definitions of surgical wound infections. Infect Control Hosp Epidemiol, 13, 606–608.

7. Horan TC, Emori TG. (1997). Definitions of key terms used in the NNIS System. Am J Infect Control, 25, 112–116.

8. Wallace WC, Cinat M, Gornick WB, Lekawa ME, Wilson SE. (1999). Nosocomial infections in the surgical intensive care unit: A difference between trauma and surgical patients. Am Surg, 65, 987–990.

9. Scheel O, Stormark M. (1999). National prevalence survey on hospital infections in Norway. J Hosp Infect, 41, 331–335.

10. Mangram AJ, Horan TC, Pearson ML, et al. (1999). Guideline for prevention of surgical site infection, 1999. Hospital Infection Control Practices Advisory Committee. Infect Control Hosp Epidemiol, 20, 250–278; quiz 279–280.

11. Cruse P. (1981). Wound infection surveillance. Rev Infect Dis, 3(4),734–7.

12. Cruse PJ, Foord R. (1980). The epidemiology of wound infection: A 10-year prospective study of 62,939 wounds. Surg Clin North Am, 60(1), 27–40.

13. Martone WJ, Jarvis WR, Culver DH, Haley RW. (1992). Incidence and nature of endemic and epidemic nosocomial infections. In: Bennett JV, Brachman PS, eds. Hospital Infections. 3rd ed. Boston: Little, Brown and Co; 577–96.

14. Boyce JM, Potter-Bynoe G, Dziobek L. (1990). Hospital reimbursement patterns among patients with surgical wound infections following open-heart surgery. Infect Control Hosp Epidemiol, 11(2), 89–93.

15. Poulsen KB, Bremmelgaard A, Sorensen AI, Raahave D, Petersen JV. (1994). Estimated costs of postoperative wound infections: A case-control study of marginal hospital and social security costs. Epidemiol Infect, 113(2), 283–95.

16. Vegas AA, Jodra VM, Garcia ML. (1993). Nosocomial infection in surgery wards: A controlled study of increased duration of hospital stays and direct cost of hospitalization. Eur J Epidemiol, 9(5), 504–10.

17. Albers BA, Patka P, Haarman HJ, Kostense PJ. (1994). Cost effectiveness of preventive antibiotic administration for lowering risk of infection by 0.25%. [German]. Unfallchirurg, 97(12), 625–8.

18. Platt R, Zaleznik DF, Hopkins CC, et al. (1990). Perioperative antibiotic prophylaxis for herniorrhaphy and breast surgery. N Engl J Med, 322, 153–160.

19. Dellinger EP, Gross PA, Barrett TL, et al. (1994). Quality standard for antimicrobial prophylaxis in surgical procedures. Infectious Diseases Society of America. Clin Infect Dis, 18, 422–427.

20. Page CP, Bohnen JMA, Fletcher JR, et al. (1993). Antimicrobial prophylaxis for surgical wounds: Guidelines for clinical care. Arch Surg, 128, 79–88.

21. Gyssens IC, Geerligs IE, Dony JM, et al. (1996). Optimising antimicrobial drug use in surgery: An intervention study in a Dutch university hospital. J Antimicrob Chemother, 38, 1001–1012.

22. Gyssens IC, Geerligs IE, Nannini-Bergman MG, et al. (1996). Optimizing the timing of antimicrobial prophylaxis in surgery: An intervention study. J Antimicrob Chemother, 38, 301–308.

23. Silver A, Eichorn A, Kral J, et al. (1996). Timeliness and use of antibiotic prophylaxis in selected inpatient surgical procedures. The Antibiotic Prophylaxis Study Group. Am J Surg, 171, 548–552.

24. Finkelstein R, Reinhertz G, Embom A. (1996). Surveillance of the use of antibiotic prophylaxis in surgery. Isr J Med Sci, 32, 1093–1097.

25. Crabtree TD, Pelletier SJ, Gleason TG, Pruett TL, Sawyer RG. (1999). Clinical characteristics and antibiotic utilization in surgical patients with Clostridium difficile-associated diarrhea. Am Surg, 65, 507–511.

26. Kurz A, Sessler DI, Lenhardt R. (1996). Perioperative normothermia to reduce the incidence of surgical-wound infection and shorten hospitalization. Study of Wound Infection and Temperature Group [see comments]. N Engl J Med, 334, 1209–1215.

27. Greif R, Akca O, Horn EP, et al. (2000). Supplemental perioperative oxygen to reduce the incidence of surgical-wound infection. Outcomes Research Group [see comments]. N Engl J Med, 342, 161–167.

28. Dellinger EP. (2001). Preventing surgical-site infections: The importance of timing and glucose control. Infect Control Hosp Epidemiol, 22, 604–606.

29. Latham R, Lancaster AD, Covington JF, et al. (2001). The association of diabetes and glucose control with surgical-site infections among cardiothoracic surgery patients. Infect Control Hosp Epidemiol, 22, 607–612.

30. Furnary AP, Zerr KJ, Grunkemeier GL, Starr A. (1999). Continuous intravenous insulin infusion reduces the incidence of deep sternal wound infection in diabetic patients after cardiac surgical procedures [see comments]. Ann Thorac Surg, 67, 352–360; discussion 360–362.

31. Olson MM, MacCallum J, McQuarrie DG. (1986). Preoperative hair removal with clippers does not increase infection rate in clean surgical wounds. Surg Gynecol Obstet, 162, 181–182.

32. Horgan MA, Piatt JH, Jr. (1997). Shaving of the scalp may increase the rate of infection in CSF shunt surgery. Pediatr Neurosurg, 26, 180–184.

33. Balthazar ER, Colt JD, Nichols RL. (1982). Preoperative hair removal: A random prospective study of shaving versus clipping. South Med J, 75, 799–801.

34. Ko W, Lazenby WD, Zelano JA, et al. (1992). Effects of shaving methods and intraoperative irrigation on suppurative mediastinitis after bypass operations. Annals of Thoracic Surgery, 53, 301–305.

35. Pomposelli JJ, Baxter JK, 3rd, Babineau TJ, et al. (1998). Early postoperative glucose control predicts nosocomial infection rate in diabetic patients. JPEN J Parenter Enteral Nutr, 22, 77–81.

36. Reason J. (2000). Human error: Models and management. BMJ, 320, 768–70.

37. Classen DC, Evans RS, Pestotnik SL, Burke JP. (1992). The timing of prophylactic administration of antibiotics and the risk of surgical-wound infection. N Engl J Med, 326, 281–6.

38. Nolan TW. (2000). System changes to improve patient safety. BMJ, 320, 771–3.

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For More information contact:

Susan Sumwalt, RN, MA, CPHQ
Clinical Quality Specialist
phone: (602) 665-6176
fax: (602) 241-0757
ssumwalt@azqio.sdps.org