Presentation at ACS NSQIP National Conference in July 2015 Surgical Site Infection Reduction Strategies
PeaceHealth Sacred Heart Medical Center at RiverBend Level II Trauma Center 379 Beds 15,060 cases in 2014 254 Colorectal cases in 2014 One of four PeaceHealth hospitals in Oregon Serves a five-county area, with reach into tertiary referral markets Among premier surgery centers in Pacific Northwest 2011 PeaceHealth 2
Among surgical patients, surgical site infections (SSIs) are the most common type of nosocomial infection, accounting for approximately 38% of these infections. The highest rates occur after abdominal and colorectal surgery. SSIs are associated with substantial morbidity and mortality, prolonged hospital stay, increased costs, and higher readmission rates. 2011 PeaceHealth 3
Our facility s SSI rates were trending upward, and in the NSQIP January 2012 SAR, the hospital was identified as a high outlier, in the 10 th decile, for SSI in all cases with a 6.05% infection rate. The hospital s colorectal SSI rate was also a high outlier, in the 10 th decile, with an infection rate of 20.71%. The colorectal SSIs accounted for 41.8% of the hospital s SSI. 2011 PeaceHealth 4
In February 2012, concurrent work was started to develop a colorectal enhanced recovery pathway, while incorporating a best practice bundle to reduce SSI rates. 2011 PeaceHealth 5
Steps in process: Our facility NSQIP model was changed to general/vascular procedure-targeted review, and the NSQIP program was expanded with a second SCR to support our expansion to multispecialty review. Data outside general/vascular was now available for department-wide quality review. A colorectal stakeholder team was assembled to create a colorectal ERAS pathway. A multidisciplinary surgery quality team was created to promote best practice within all of Surgical Services. Primary focuses were SCIP bundle compliance, hand-washing, and reduction of SSI and UTI. 2011 PeaceHealth 6
Surgery Leadership NSQIP SCR s Surgeons Infection Prevention Multidisciplinary Surgery Quality Team Anesthesia Pharmacy Surgery Quality Analytics 2011 PeaceHealth 7
SSI Prevention Bundle Pre-operative Elements Chlorhexidine gluconate (CHG) shower x 3 prior to surgery Remove hair with clippers Cleanse skin with CHG impregnated wipes Preoperative warming Observe good hand hygiene Bowel prep-use of oral antibiotics with mechanical bowel prep Intra-operative Elements SCIP acceptable antibiotics Re-dose antibiotics intra-op per protocol Chloraprep for skin prep Use sufficient number of applicators Correct technique for all port sites Duraprepif allergy to CHG Betadine for stomas Wound protector Clean wound closure protocol Clean instruments Cautery Suction Light handles Change gowns, gloves Saline irrigation of wound after fascia is closed Dry occlusive dressing Post-operative Elements Daily post-op bathing with CHG and discharge with CHG for bathing at home Maintain dry occlusive dressing, change if needed Dressing removal within 48 hrs after surgery Consider wound probing or wicks if dirty or contaminated Culture wound if concern for infection Observe good hand hygiene Observe good hand hygiene 2011 PeaceHealth 8
Documentation Specialist Colorectal Surgeons NSQIP SCR's General Surgery Office Nurse Leadership Perioperative Nurse Educators Colorectal Stakeholder Team Surgery Leadership Anesthesia Perioperative Nurse Managers Pharmacy Dietary 2011 PeaceHealth 9
Elements of Colorectal Pathway Preoperative patient education with discharge planning Standardized pre-op bowel preps with oral antibiotics Pre-operative analgesics and nausea & vomiting prophylaxis Preoperative carbohydrate loading Extensive use of regional anesthesia (epidural catheters) Use of laparoscopic approach or minimize incisional length. Maintain intra-operative euvolemia
Elements of Colorectal Pathway Active warming No post-operative NG tubes Avoid drains Minimize intra-operative and post-operative opiods Regular low residue diet 4 hours postop Enforced ambulation Scheduled acetaminophen, gabapentin, and NSAID s
SHMC Clinical Pathway Colorectal Surgery Expected Activities/Out comes Office (Scheduling Surgery) Give Pamphlet & Educate on ambulation & sitting post-op Pre- Admission Testing plus Education Surgery education Place Colorectal pathway on chart Pre-Op (SPA) -Arrive 2hr early Prior to surgery -Surgery education -Prepare for surgery Intra-Op Post-Op POD #1 POD #2 POD #3 Minimal Fluid loading Ambulate/sit early, advance diet quickly, avoid PCA & narcotics (use multimodal pain regime) Resp Education about IE IE & education IE 6-10x/hr while awake SpO2>92% CV DVT prevention Educate on taking beta-blocker Educate on SCD use and anticoagulation meds Take Beta-blocker with sips Confirm Pt. Took beta-blocker SCD put on unless contraindicated SCD s turned on prior to intubation Continue on beta blocker postoperatively SCD s while in bed Anticoagulants as ordered -Progressive ambulation & sitting during day -Sit for all meals Continue IE 6-10x/hr while awake SCD s while in bed Anticoagulants as ordered Increase & progress all POD #1 expected Outcomes Continue IE 6-10x/hr while awake SCD s while in bed Anticoagulants as ordered -DC by time -Home Continue IE 6-10x/hr while awake SCD s while in bed Anticoagulants as ordered GI (reduce postop ileus) Educate on diet: Drinking & eating crackers post-op 1 st 4hrs, then light diet, 2 clear liquid supplemental drinks/day (1 postop) -NPO teaching -Post Op Dietary teaching & expectations NPO Except for meds with sips of H2O GU Foley teaching Insert urethral Foley Fluid & Electrolytes IV per anesthesia Skin/Drains Clip hair for abdominal prep IV per anesthesia Minimal Fluid loading Possible NG, JP or pain pump placed -Full Liquid Diet + crackers first 4hrs then -Advance to Post Surgical Light Diet -Encourage fluids: 800cc/day to include 1 supplement by midnight -If NG NPO /c ice prn Urine Output > 160ml/shift -IV fluid as ordered -Oral fluids as above in GI Reinforce/change dressing PRN -Post Surgical Light Diet -Encourage 1500-2500ml fluid/day include 2 supplemental drinks Dietary Consult Remove Foley if ordered -Voiding if Foley DC d -Saline lock IV in AM -Oral fluids as above in GI Reinforce/change dressing PRN Low Residue Diet -2 supplemental nutritional drinks/day -Remove Foley if ordered -Voiding if Foley DC d Remove dressing Voiding SSI s prevention Pain Management Encourage frequent hand washing Educate on multimodal pain regime & avoidance of narcotics Shower prep packs given More pain management Teaching/education & expectations -Inquire if shower prep pre-op? -Chlorhexadine wipes (2%) -Teaching -Give Pre op pain meds 90min prior -Possible: Spinal, Epidural,, or Accufusor -Give ABX before incision -surgical prep Give NSAID before incision Give ABX (last dose to be within 24 hrs of surgery end time) Cont. with multi med regimen for pain Lab tests BMP & CBC Monitor Monitor -D/C Toradol and start PO NSAIDS -DC pain pump if used Consults & DC Planning Surgeon & scheduler Anesthesia pre-op consult time-out verification Social work for DC planning *If new ostomy patient- nrsg referral to Ostomy Office PT/OT/Social work for DC planning assess & tx Discharge Planning Discharge home 2011 PeaceHealth 12
SHRB SSI- NSQIP Odds Ratio Quarter 1 and Quarter 2 of 2011 were statistically worse than expected.
1. General surgeons meet to discuss NSQIP results. 2. Emphasis on hand hygiene housewide. 3. Chlorhexidine shower night before and day of surgery. 4. Chlorhexidine wipes implemented in surgical prep area. 5. Use of chlorhexidine surgical prep & reinforcement of correct technique for OR staff.
1. Mechanical bowel prep & pre-op oral antibiotics introduced. 2. Standard use of wound protectors. 3. SCIP pre-op bundle for all patients: timing, antibiotic selection, dose, redose. 4. Order sets changed to reflect SCIP pre-op bundle 5. Euvolemic volume replacement introduced.
BairPaws implemented to promote normothermia.
1. Full implementation of colorectal pathway begins. 2. RN concurrent reviewer provides feedback to surgeon on documentation to avoid SCIP misses. 3. Gown/gloves changed as appropriate during surgery.
1. Clean closure process & instrument set introduced to staff and surgeons. 2. Carbohydrate loading introduced for colorectal pathway patients.
Colorectal pathway and SSI bundle were re-evaluated by colorectal stakeholder team and surgery quality team.
Quarter 1 and Quarter 2 of 2014 were statistically better than expected.
20.00% Colorectal SSI rate (raw data) 18.00% 16.00% 14.00% 12.00% 10.00% 8.00% Colorectal SSI rate 6.00% 4.00% 2.00% 0.00% 2010 2011 2012 2013 2014 2011 PeaceHealth 21
SSI Improvement in Colorectal Surgery Patients 2011 277 total cases 17.32% infection rate Quarter 20f 2011 Infection rate of 24.24% in 66 colorectal surgery patients. 2014 254 total cases 3.54% infection rate Quarter 4 of 2014 Infection rate of 0% in 51 colorectal surgery patients 2011 PeaceHealth 22
Current SSI trend chart 2011 PeaceHealth 23
Return on Investment- SSI Reduction (from ACS NSQIP ROI calculator) # SSI decrease from previous year Cost savings 2012-25 $690,775 2013-22 $607,882 2014-13 $359,203 $1,657,860 2011 PeaceHealth 24
Next steps: Peri-operative glucose control Further scrutiny of bowel prep Clean closure process improvement Nutritional optimization Re-educate nurses on surgical prep technique 2011 PeaceHealth 25
Conclusions: A best practice SSI reduction bundle combined with ERAS colorectal protocol resulted in dramatic improvement of overall SSI rates and postoperative morbidity. Developing a multidisciplinary team was critical to our success. Best practice guidelines were researched and followed. Using NSQIP data to drive decision making and actions with continual data review, including benchmarked and raw data, was essential to achieve our results. Multimodal interventions to reduce SSI have resulted in significant, sustained improvement in our facility s overall SSI rates. 2011 PeaceHealth 26