Reducing Surgical Site Infection after Major Gynecologic Cancer Surgery

Transcription

1 Reducing Surgical Site Infection after Major Gynecologic Cancer Surgery Sharon J. Kim Mayo Medical Student Mayo Clinic, Rochester, MN ACS NSQIP National Conference July 27, MFMER slide-1

2 Disclosure X No, nothing to disclose Yes, please specify: 2015 MFMER slide-2

3 SSI after Gynecologic Cancer Surgery Increased morbidity and mortality in ovarian cancer Organ/space SSI 1.5-fold increased risk of death Superficial SSI 1.7-fold increased risk of death Increased Costs 30-day median costs for endometrial cancer at Mayo: $9500 per Superficial; $20,000 per Organ/Space SSI Pay for Performance: CMS reports institutional data and allows patients to compare hospital performance Bakkum-Gamez, et al. Gynecologic Oncology Tran, et al. Gynecologic Oncology Anderson, et al. Inf Control Hosp Epi MFMER slide-3

4 SSI Causes are Multifactorial Age Obesity Malnutrition Cancer Diabetes Immunosuppression ASA score Disease severity Prior operations Prior chemotherapy Prior radiation Biologics Nasal/skin carriage Virulence Adherence Inoculum Host Factors Endogenous flora Surgical procedures Surgical Team & Hospital Practice Incision site Wound classification Procedure duration Hemostasis Drains/foreign bodies Dead space Urgency of surgery Razor shaves Intraoperative contamination Prophylactic antibiotics Preoperative cleansing Surgeon s skill Surgical volume 2015 MFMER slide-4

5 Turning to the SSI Reduction Bundle Surgical Care Improvement Project (SCIP) implementation Not shown to effectively lower SSI rates Bundle: a set of evidence-based practices that, when performed collectively and reliably, have been proven to improve patient outcomes Common elements: hair removal, normothermia, glycemic control, gown and glove change Hawn, et al. Ann Surgery MFMER slide-5

6 SSI Reduction Bundle Several small scale studies have shown SSI reduction with the synergistic effect of a bundle Colorectal Surgery at Mayo: SSI reduction bundle for entire surgical episode Overall SSI baseline 9.8% 4% (p<0.05) Superficial incisional SSI: 4.9% 1.5% (p<0.05) Revolus, et al. Obstet Gynecol Waits, et al. Surgery Cima, et al. JACS MFMER slide-6

7 Quality Improvement Project Design Multidisciplinary Approach Case inclusion criteria: Type 2 laparotomies for ovarian cancer with and without bowel resection and uterine cancer Data Sources: Mayo Infection Prevention and Control (IPAC), NSQIP, CPT, ICD-9 Codes Goal: Reduce SSI rates by 50% 2015 MFMER slide-7

8 Cima, et al. JACS Mayo Clinic SSI Reduction Bundle 2015 MFMER slide-8

9 Overall SSI Rates by Month Pre-intervention SSI rate of 5.9% decreased by 74.6% to 1.5% during intervention period (p=0.01) 2015 MFMER slide-9

10 SSI Rates per Procedures Overall reduction of 74.6% (p=0.01) Odds ratio reduced from 1.59 to 0.6 Procedure Pre-Intervention Intervention P Reduction Ovarian cancer without BR Ovarian cancer with BR 13/275 (4.7%) 1/105 (1.0%) % 12/116 (10.3%) 2/44 (4.5%) % Uterine cancer 14/269 (5.2%) 0/50 (0.0%) % All 39/660 (5.9%) 3/199 (1.5%) % BR = Bowel Resection 2015 MFMER slide-10

11 SSI Reduction per Infection Type Superficial incisional SSI 12/660 (1.8%) 1/199 (0.5%) 72% reduction (p=0.32) Deep incisional SSI 2/660 (0.3%) 0/199 (0%) Organ/space SSI 25/660 (3.8%) 2/199 (1.0%) 74% reduction (p=0.05) 2015 MFMER slide-11

12 Mayo Clinic Gyn NSQIP SSI Decile Ranking Time Frame 2015 MFMER slide-12

13 30-Day SSI Rates in Gynecologic Surgery Implementation of full bundle 2015 MFMER slide-13

14 Limitations, Strengths, and Future Interventions Element driving risk reduction in bundle unknown Independent audit of SSI by IPAC Strong team champions from each specialty Future interventions to consider: Preoperative oral antibiotics in bowel resection Prophylactic Negative Pressure Wound Therapy Nasal MRSA screening Hendren, et al. Annals of Surgery Cannon, et al. Diseases of the Colon & Rectum Lewis, et al. Gynecol Oncol Matsubara, et al. Surgery Today MFMER slide-14

15 In Summary Risk factors for SSI are multifactorial and often non-modifiable Implementing a bundle of evidence-based practices resulted in significant and sustained SSI reduction Future study in cost:benefit analyses necessary Preoperative oral antibiotics, NPWT, and MRSA screenings are additional areas for exploration 2015 MFMER slide-15

16 Acknowledgements: Megan P. Johnson, PA-C, Division of Gynecologic Surgery Carrie L. Langstraat, MD, Division of Gynecologic Surgery Sneha Jain, MHA, CSSBB, Quality Improvement Project Advisor Elizabeth B. Habermann, PhD, Division of Healthcare Policy and Research Jean E. Wentink, RN, BSN, Infection Prevention and Control Pamela L. Grubbs, MS, APRN, CNS, Department of Nursing Sharon A. Nehring, RN, Surgery Research Office Amy L. Weaver, MS, Division of Biomedical Statistics and Informatics Michaela E. McGree, BS, Division of Biomedical Statistics and Informatics Robert R. Cima, MD, Division of Colorectal Surgery Sean C. Dowdy, MD, Division of Gynecologic Surgery, NSQIP Champion Jamie N. Bakkum-Gamez, MD, Division of Gynecologic Surgery 2015 MFMER slide-16