EMERGING EVIDENCE AND BEST PRACTICES TO PREVENT SSI IN COLON PROCEDURES

EMERGING EVIDENCE AND BEST PRACTICES TO PREVENT SSI IN COLON PROCEDURES Clifford Ko, MD, MS, MSHS, FACS, FASCRS Professor of Surgery UCLA Director, ACS NSQIP, American College of Surgeons

EVIDENCE Ban et al., JACS 2017

SSI RISK FACTORS Intrinsic (patient related) non-modifiable: increased age, recent xrt, history of skin or soft tissue infection; modifiable: diabetes, obesity, alcoholism, current smoker, pre-op albumin <3.5, total bilirubin>1.0, immunosuppression

SSI RISK FACTORS Intrinsic (patient related) non modifiable: increased age, recent xrt, history of skin or soft tissue infection; modifiable: diabetes, obesity, alcoholism, current smoker, pre-op albumin <3.5, total bilirubin>1.0, immunosuppression Extrinsic (procedure related) Procedure emergency, increased complexity, higher wound classification Facility inadequate ventilation, increased operating room traffic, contaminated environmental surfaces, non sterile equipment Preoperative pre existing infection, inadequate skin preparation, inappropriate antibiotic choice, timing, and dosing, hair removal method, poor glycemic control Intraoperative longer procedure duration, blood transfusion, breach in asepsis, inappropriate antibiotic redosing, inadequate gloving, inappropriate surgical scrub, poor glycemic control

AMERICAN COLLEGE OF SURGEONS SURGICAL INFECTION SOCIETY Prehospital Interventions preoperative bathing, smoking cessation, glucose control, MRSA screening, bowel preparations Hospital Interventions glucose control, hair removal, skin preparation, surgical hand scrub, surgical attire, antibiotic prophylaxis, intraoperative normothermia, wound protectors, antibiotic sutures, gloves, instruments, wound closure, topical antibiotics, supplemental oxygen, wound care Post Discharge wound care, SSI surveillance

DO SURGICAL CARE BUNDLES REDUCE THE RISK OF SSI IN COLORECTAL SURGERY? Yes!

A SYSTEMATIC REVIEW AND COHORT META ANALYSIS OF 8515 PATIENTS Review of RCTs, quasi experimental studies, and cohort studies of care bundles to reduce SSI 2012 2014 16 studies SSI rate in bundle group: 7.0% SSI rate in standard group: 15.1% Risk Reduction: 0.55 (0.39-0.77; P=0.0005) Tanner et al., Surgery 2015

BUNDLE COMPONENTS (1 12) 1. Appropriate antibiotic selection/dose (14 bundles) 2. Prophylactic antibiotics within 60 min before surgery (14) 3. Prophylactic antibiotics discontinued within 24 h (9) 4. Antibiotic re-dose within 3-4 h after incision (4) 5. Glycemic control (8) 6. Normothernia preoperatively (5) 7. Normothermia intra-operatively (9) 8. Normothermia postoperatively (10) 9. Appropriate hair removal (9) 10. Supplemental oxygen (3) 11. Systolic pressure >90mmHg (1) 12. Reduction in intravenous fluids during operation (1)

BUNDLE COMPONENTS (13 24) 13. Wound edge protector (2) 14. CHG cloths on admission (1) 15. Preoperative CHG wipes or shower (4) 16. CHG in alcohol skin preparation (4) 17. Double gloving (1) 18. Glove and/or gown change (2) 19. Theatre discipline/restricted traffic (2) 20. Smoking cessation (1) 21. Patient SSI education (3) 22. Tray for closure of fascia and skin (3) 23. Omission of mechanical bowel preparation (1) 24. Mechanical bowel preparation plus oral antibiotics (3)

BUNDLE COMPONENTS (25 32) 25. Oral antibiotics given with mechanical bowel prep if used (1) 26. Penrose drain for patients with BMI?25kg/m^2 (1) 27. Pulse lavage of subcutaneous tissue (1) 28. Minimally invasive surgery (1) 29. Short duration of surgery (1) 30. Silver dressings for 5 days (1) 31. Removal of sterile dressing within 48 h (2) 32. Postoperative washing of wound with CHG (2)

META ANALYSIS RESULTS: SURGICAL CARE BUNDLES REDUCE THE RISK OF SSI

WHAT BUNDLE SHOULD WE USE??

CONSIDER (AND EMBRACE) EQUIFINALITY Many All roads lead to Rome

Each Hospital had different factors associated with their SSI rates

Each Hospital had different factors associated with their SSI rates

So, in order to address these differing local factors, each hospital had a different solution for decreasing its SSI rate

Different Hospitals Different Solutions; Different paths, timing All Hospitals Reached Their Goal of Achieving Improvement

OPTIMAL SURGICAL RECOVERY Fast track Enhanced Recovery After Surgery ERAS Pathway Bundle

WHAT IS THE AMERICAN COLLEGE OF SURGEONS OPTIMAL SURGICAL RECOVERY PROGRAM? It is a free program sponsored by the American College of Surgeons that offers a surgical care pathway which is evidence-based, proven to improve perioperative care, reduce variability, and improve outcomes (including SSI). Key elements include:

WHAT IS THE AMERICAN COLLEGE OF SURGEONS OPTIMAL SURGICAL RECOVERY PROGRAM? It is a free program sponsored by the American College of Surgeons that offers a surgical care pathway which is evidence-based, proven to improve perioperative care, reduce variability, and improve outcomes (including SSI). Key elements include: Patient and family engagement State of the art analgesia Early mobility and restoration of functional status Avoidance of prolonged periods of fasting Evidence based best practices for SSI, VTE, and CAUTI prevention

Overarching Goal: to incorporate standardized evidence-based practice. Standardize how we do things

AN EXAMPLE OF AN OPTIMAL SURGICAL RECOVERY PROTOCOL 1. Preadmission counseling 2. Preoperative clears until 3 hours before induction 3. Epidural anesthesia for open resections 4. Multi-modal pain management 5. Normothermia on arrival to recovery room 6. Intraoperative goal directed IVF therapy 7. PONV assessment and prophylaxis 8. Mobilization, POD 0-1, POD 1-2, and POD 2-3 9. Clear liquids provided in the first 24 hours postop 10. Solids provided in 24-48 hours postop 11. Foley removed on or before POD 1 12. IVF discontinued POD 0-1

AN EXAMPLE OF AN OPTIMAL SURGICAL RECOVERY PROTOCOL 1. Preadmission counseling PREOP NURSING 2. Preoperative clears until 3 hours before induction 3. Epidural anesthesia for open resections 4. Multi-modal pain management 5. Normothermia on arrival to recovery room 6. Intraoperative goal directed IVF therapy 7. PONV assessment and prophylaxis 8. Mobilization, POD 0-1, POD 1-2, and POD 2-3 9. Clear liquids provided in the first 24 hours postop 10. Solids provided in 24-48 hours postop 11. Foley removed on or before POD 1 POSTOP NURSING 12. IVF discontinued POD 0-1 ANESTHESIA SURGERY PHARMACY MID LEVELS

LOOK AT YOUR OWN DATA RE: COMPLIANCE WITH PROTOCOL Enhanced recovery element PRE ADMISSION COUNSELING 407 (54%) ALLOW CLEAR LIQUIDS UP TO 3HR PREOP 259 (35%) THORACIC EPIDURAL ANESTH 207 (28%) GOAL DIRECTED FLUID THERAPY INTRAOP 400 (54%) NORMAL TEMP ON ARRIVAL PACU 712 (95%) MULTI-MODAL PAIN MANAGEMENT 718 (95%) MULTI-MODAL ANTIEMETIC PROPHYLAXIS 678 (90%) MOBILIZATION POD0 406 (60%) PATIENT GIVEN CLEAR LIQUIDS POD0 449 (61%) IV FLUIDS DISCONTINUED POD1 123 (16%) MOBILIZATION BID POD1 479 (73%) SOLIDS GIVEN POD1 350 (48%) FOLEY REMOVED POD1 484 (66%) N, % Receiving after ERAS implementation

Enhanced recovery element GOOD COMPLIANCE PRE ADMISSION COUNSELING 407 (54%) ALLOW CLEAR LIQUIDS UP TO 3HR PREOP 259 (35%) THORACIC EPIDURAL ANESTH 207 (28%) GOAL DIRECTED FLUID THERAPY INTRAOP 400 (54%) NORMAL TEMP ON ARRIVAL PACU 712 (95%) MULTI-MODAL PAIN MANAGEMENT 718 (95%) MULTI-MODAL ANTIEMETIC PROPHYLAXIS N, % Receiving after ERAS implementation 678 (90%) MOBILIZATION POD0 406 (60%) PATIENT GIVEN CLEAR LIQUIDS POD0 449 (61%) IV FLUIDS DISCONTINUED POD1 123 (16%) MOBILIZATION BID POD1 479 (73%) SOLIDS GIVEN POD1 350 (48%) FOLEY REMOVED POD1 484 (66%)

Enhanced recovery element FIND THINGS TO WORK ON PRE ADMISSION COUNSELING 407 (54%) ALLOW CLEAR LIQUIDS UP TO 3HR PREOP N, % Receiving after ERAS implementation 259 (35%) THORACIC EPIDURAL ANESTH 207 (28%) GOAL DIRECTED FLUID THERAPY INTRAOP 400 (54%) NORMAL TEMP ON ARRIVAL PACU 712 (95%) MULTI-MODAL PAIN MANAGEMENT 718 (95%) MULTI-MODAL ANTIEMETIC PROPHYLAXIS 678 (90%) MOBILIZATION POD0 406 (60%) PATIENT GIVEN CLEAR LIQUIDS POD0 449 (61%) IV FLUIDS DISCONTINUED POD1 123 (16%) MOBILIZATION BID POD1 479 (73%) SOLIDS GIVEN POD1 350 (48%) FOLEY REMOVED POD1 484 (66%)

EARLY RESULTS OF IMPLEMENTING STANDARDIZATION LOS N Days Pre Average of 3 years 7.3/7.7 Post 179 / 6 months 4.4 SSI N % Pre 800 /yr 20 Post 247 6

INITIATING AN EFFORT TO ACHIEVE SYSTEM WIDE IMPLEMENTATION AN INVITATION TO JOIN OPTIMAL SURGICAL RECOVERY PROGRAM COORDINATED BY THE AMERICAN COLLEGE OF SURGEONS Recruitment starting now (>1000 Hospitals/Hospital Systems) Free Evidence reviews, localizable protocols, expert thought leaders, NSQIP-like data platform/reports, patient materials For more information, please email: OSR@facs.org

THANK YOU!

EMERGING EVIDENCE AND BEST PRACTICES TO PREVENT SSI IN COLON PROCEDURES Clifford Ko, MD, MS, MSHS, FACS, FASCRS Professor of Surgery UCLA Director, ACS NSQIP, American College of Surgeons