Surgical Infection PreventionSurgical Infection Prevention

Project Team:Project Team:Anesthesia Anesthesia Infectious Disease Infectious Disease PharmacyPharmacySurgical ServicesSurgical ServicesLabor & Delivery Labor & Delivery Quality Resource Management Quality Resource Management Center for Clinical EffectivenessCenter for Clinical Effectiveness

Opportunity StatementOpportunity Statement

Surgical site infections are a major Surgical site infections are a major complication after surgery, resulting in complication after surgery, resulting in considerable morbidity, mortality, and considerable morbidity, mortality, and resource utilization. Proper use of resource utilization. Proper use of antibiotics – giving the right drug and the antibiotics – giving the right drug and the right time – is effective in preventing right time – is effective in preventing infections after surgery.infections after surgery.

Project GoalsProject Goals

To achieve 100% compliance for the To achieve 100% compliance for the following measures:following measures:

1.1. Administer antibiotics within one hour Administer antibiotics within one hour before surgical incisionbefore surgical incision

2.2. Administer the appropriate antibioticAdminister the appropriate antibiotic3.3. Stop antibiotics within 24 hours after Stop antibiotics within 24 hours after

surgerysurgery

Defined by the National Surgical Infection Prevention Project (CMS/CDC)Defined by the National Surgical Infection Prevention Project (CMS/CDC)

Targeted SurgeriesTargeted Surgeries

Abdominal and Vaginal HysterectomyAbdominal and Vaginal Hysterectomy

Hip and Knee ReplacementHip and Knee Replacement

Cardiac BypassCardiac Bypass

Other Cardiac SurgeryOther Cardiac Surgery

Vascular SurgeryVascular Surgery

Colon SurgeryColon Surgery

Most Likely CausesMost Likely Causes

Antibiotic not administered within Antibiotic not administered within recommended time intervalsrecommended time intervals

Variation in physician ordering practicesVariation in physician ordering practices

Variation in documentation of antibiotic Variation in documentation of antibiotic administrationadministration

Solutions ImplementedSolutions Implemented

Initiated extensive data collection planInitiated extensive data collection planBased on CMS and JCAHO specificationsBased on CMS and JCAHO specificationsMonthly chart reviewMonthly chart review

Shared service specific dataShared service specific dataReviewed with Physicians and Nurse Reviewed with Physicians and Nurse PractitionersPractitionersIdentified improvement opportunitiesIdentified improvement opportunities

Revised pre and post operative standard Revised pre and post operative standard order sets to mirror guidelinesorder sets to mirror guidelines

Definition: Surgical patients who received prophylactic antibiotics within 60 minutes prior to surgical incision / Patients undergoing CABG, cardiac surgery, hip / knee arthroplasty, colon surgery, hysterectomy, or vascular surgery. Vancomycin and fluoroquinolones timeframe is extended to 120 minutes prior to incision.

Data source: LUMC medical records abstracted by RNs.

Per

cen

t

National Hospital Quality MeasuresSurgical patients receiving prophylactic antibiotics

within one hour prior to surgical incision

Month

Apr-0

4 (n

=67)

May

-04

(n=5

0)

Jun-

04 (n

=58)

Jul-0

4 (n

=55)

Aug-0

4 (n

=48)

Sep-0

4 (n

=43)

Oct-04

(n=5

0)

Nov-0

4 (n

=51)

Dec-0

4 (n

=55)

70

75

80

85

90

95

100

105UCL = 102.96

LUHS Mean = 91.4

LCL = 79.85

JCAHO National Rate Q3 2004: 72.0

Ninety percent of LUMC patients receive prophylactic Ninety percent of LUMC patients receive prophylactic antibiotics within 60 minutes prior to surgical incisionantibiotics within 60 minutes prior to surgical incision

Definition: Surgical patients receiving prophylactic antibiotics consistent with current guidelines / Patients undergoing CABG, cardiac surgery, hip / knee arthroplasty, colon surgery, hysterectomy, or vascular surgery.

Data source: LUMC medical records abstracted by RNs.

Per

cen

t

National Hospital Quality MeasuresSurgical patients receiving prophylactic antibiotics

consistent with current guidelines

Month

Apr-0

4 (n

=61)

May

-04

(n=4

8)

Jun-

04 (n

=55)

Jul-0

4 (n

=53)

Aug-0

4 (n

=47)

Sep-0

4 (n

=42)

Oct-04

(n=4

6)

Nov-0

4 (n

=51)

Dec-0

4 (n

=50)

65

70

75

80

85

90

95

100UCL = 98.89

LUHS Mean = 83.0

LCL = 67.12

JCAHO National Rate Q3 2004: 92.0

Eighty three percent of LUMC patients receive Eighty three percent of LUMC patients receive prophylactic antibiotics consistent with current guidelinesprophylactic antibiotics consistent with current guidelines

Definition: Surgical patients with prophylactic antibiotics discontinued within twenty-four hours after surgery end time / Patients undergoing CABG, cardiac surgery, hip / knee arthroplasty, colon surgery, hysterectomy, or vascular surgery.

Data source: LUMC medical records abstracted by RNs.

Per

cen

t

National Hospital Quality MeasuresSurgical patients receiving prophylactic antibiotics

discontinued within 24 hours after surgery end time

Month

Apr-0

4 (n

=62)

May

-04

(n=4

4)

Jun-

04 (n

=57)

Jul-0

4 (n

=54)

Aug-0

4 (n

=44)

Sep-0

4 (n

=40)

Oct-04

(n=4

8)

Nov-0

4 (n

=49)

Dec-0

4 (n

=51)

50

60

70

80

90

UCL = 87.00

LUHS Mean = 67.0

LCL = 47.07

JCAHO National Rate Q3 2004: 63.0

Two-third of LUMC patients now have prophylactic Two-third of LUMC patients now have prophylactic antibiotics discontinued within 24 hours after surgery endantibiotics discontinued within 24 hours after surgery end

Analysis of ResultsAnalysis of Results

Loyola performs better than National JCAHO Loyola performs better than National JCAHO comparison hospitals for two of the measurescomparison hospitals for two of the measures

Antibiotic selection requires ongoing attention Antibiotic selection requires ongoing attention and follow upand follow up

Discontinuation of antibiotics within 24 hour Discontinuation of antibiotics within 24 hour has the greatest improvement potential for has the greatest improvement potential for Cardiovascular and Orthopaedic surgeriesCardiovascular and Orthopaedic surgeries

Next StepsNext Steps

Continue comparison with UHC and national Continue comparison with UHC and national benchmarksbenchmarks

Post results on the LUHS portal and internetPost results on the LUHS portal and internet

Review surgical site infection data for targeted Review surgical site infection data for targeted class 1 surgeriesclass 1 surgeries

Plan for public reporting of dataPlan for public reporting of data

Consider participation in upcoming National Consider participation in upcoming National Surgical Care Improvement ProjectSurgical Care Improvement Project