QI Successes & Failures Learning from Both

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Shana Spencer
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1 QI Successes & Failures Learning from Both E. Patchen Dellinger, MD, FACS, FIDSA, FSHEA Professor of Surgery University of Washington Medical Center (UWMC), Seattle, Washington

2 Conflict of Interest Over the past year Dr. Dellinger has received research funding and/or consultation fees from 3M and in the past dozens of other companies. He has never participated in any speakers bureaus and never uses company produced slides. This talk refers to no products of any of these companies.

3 Things Don t Always Happen the Way We Think They Do 1994 antibiotic prophylaxis guideline Administer during hour before incision That s how they were ordered It s not how it was actually done

4 Good Ideas Don t Always Get Carried Out Conversations at the Infection Control Committee We should look at when our prophylactic antibiotics are actually being given. That s a good idea. We should do that. Later - Opportunity to join a national collaborative

5 It Pays to Take Advantage of Outside Opportunities 2003 CMS Surgical Infection Prevention Collaborative (SIP) forerunner to SCIP Qualis (QIO), IHI, & 56 Hospitals focus on SSI prevention in 4 meetings over 13 months

6 Locally at UWMC Improved antibiotic choice and dosing with preprinted orders Near perfect antibiotic timing and pre-warming Antibiotic administration by anesthesia instead of preop nurses Razors removed from O.R.s Started work on intra-operative glucose control O.R. algorithms Reliable IV pumps Glucometer at every anesthesia station

7 How Do We Get Our SSI (Other Complication) Rate As Low As Possible? Do everything we know how to that lowers the risk of SSI (that Other Complication)

8 How Do You Do That? Work on one thing at a time. Succeed on item one. Then move to item two. Then...

9 Potentially Preventable SSI An infection in which investigation of the circumstances demonstrates that the medical/surgical team did not do all that they could do and intended to do that would reduce SSI risk.

10 Apparently Unpreventable SSI An infection that occurred in the setting in which every known preventive measure had been taken.

11 How Do You Prevent Potentially Preventable Infections? Start with a simple definition of what you do to prevent SSI. Succeed on definition one. Then add another item to the definition. Then...

12 How Do You Prevent Potentially Preventable Infections? Start with a simple definition of what you do to prevent SSI. Give the correct prophylactic antibiotic at the correct time and with correct dose.

13 Start Pot Prev SSI Proph Antibiotic Add Temp & Glucose

14 0.90% Clean Wound SSI 0.80% 0.70% 0.60% 0.50% 0.40% 0.30% 0.20% 0.10% Start Pot Prev SSI Add Temp & Glucose 0.00%

15 Glucose and SSI

16 Glucose Control Proven important for SSI risk: Cardiac surgery General surgery Colorectal surgery Vascular surgery Breast surgery Gynecologic Oncology surgery Hepato-pancreatico-biliary surgery Orthopedic surgery Trauma surgery

17 Regardless of the Diagnosis of Diabetes (or not) Hyperglycemia Increases Morbidity Mortality Length of Stay

18 Glucose Levels & SSI The exact best level of glucose control in the perioperative period is not known. High glucose levels unequivocally increase the risk of SSI and other perioperative infections. Tight glucose control in the perioperative period is tricky. Hypoglycemia increases the risk of morbidity and mortality.

19 Hyperglycemia is Dangerous to NonDiabetic (and Diabetic) Surgical Patients 1. Before 2016 UWMC did not have an organized approach to monitoring & control. 2. We pulled together a multidisciplinary group in March 2015 (Surgery, Anesthesia, Pharmacy, Nursing, Infection Control, CCE, Hospital Medicine). 3. The group formulated a plan for testing every surgical patient pre- and intra-op and worked with the Pre-Op staff on details. 4. We scheduled a combined Surgery & Anesthesia Grand Rounds to introduce the plan with presentations from both Surgery and Anesthesia.

20 Current Progress We started testing every patient in PreOp and in the O.R. and treating those with glucose>140 in the first week of January We established the UWMC Surgical Glucose Management site which records every blood sugar value on every surgical patient day of surgery and POD #1 & 2 and insulin use. We have continued to meet in our multidisciplinary group to monitor progress.

21 Current Status Perioperative glucose testing has increased. Insulin use for hyperglycemia is still less than ideal. Hypoglycemia has not been an issue.

22 Final Thoughts A surgeon can t do quality alone. Others can t do surgical quality without surgeon involvement and commitment. Without interdisciplinary teamwork no one can do quality. The job never stops.

Preoperative Screening for Hyperglycemia Risk, Preoperative CHO, and Perioperative Glucose Control. E. Patchen Dellinger, MD

Preoperative Screening for Hyperglycemia Risk, Preoperative CHO, and Perioperative Glucose Control E. Patchen Dellinger, MD Disclosure Slide Dr. Dellinger has worked in the area of clinical trials with