If at first you don’t succeed…

Karen AndersonKim Stanley

Objectives

1.Describe the importance of a MD quality champion

2.Discuss the necessity of verifiable data

3.Describe methods to get to the core issues

One Smart IP Chick The value of manual review

Just happens to notice what may be a trend… Starts collecting data Compares to national rates (NHSN) Performs a literature search

Finding someone to take the time to listen Harder than we thought

If at first you don’t succeed… Do you give up?

NO WAY!!! ‘Giving up’ is not in the IP code

Collect more data for stronger case

Start peeling the

Keep digging Comparison to National Data

Apples to apples may not be what it appears Search the literature

Understand what the literature shows (e.g. case definitions vary)

Ask colleagues what they are seeing Go back to slide #2 – FIND SOMEONE

important who is interested Make your case with data

Our Story

Our surveillance included all NHSN breast procedures 96% of complex SSIs found in

mastectomy patients 81% were immediate post reconstruction

95% in Tissue Expanders (TE)

Case Review

Patient Risk factors Implant Placement Chemotherapy Radiation Prophylactic or

Therapeutic Mastectomy?

Acellular dermal matrix

Type of Mastectomy- nipple sparing or not?

Surgeon- Plast and Gen

Organisms Skin Preparation Preop CHG bathing Preoperative/postop

antibiotics First outpatient saline

fill date/technique Early or late

infections

Data Analysis

Of statistical significance: Nipple Sparing vs. Non-Nipple Sparing

(p value= 0.0083)

Nipple Sparing with Subcutaneous placement vs. Submuscular placement

(p value= 0.0395)

What We Did

Brought to light an issue that the surgeons (General and Plastic) were not acutely aware of Opened the dialog between our departments:

Correct skin pens for use with CHG Skin antisepsis Preoperative antibiotics Preoperative skin bathing Skin antisepsis prior to accessing port for outpatient saline

fill No multidose vials of saline for outpatient clinics

Created a patient risk questionnaire to gather additional information on all patients undergoing TE

What We Did Started a preoperative CHG bathing program

for patients undergoing mastectomy with immediate reconstruction. Preop and post op patient education created

We are still in the process of addressing the creation of evidence-based surgical guidelines and the outpatient technique for filling Tissue Expanders. Still attend at least two Plastic Surgery

Dept meetings a year to provide updates, receive feedback.

Lessons Learned Do not give up Find a respected champion and get them interested Know your data inside out and backwards

You will be challenged by the surgeons Do your homework- know what the literature shows

Understand how infection definitions may differ in published studies- they may not apply

Ask the surgeons for ideas/guidance Make it obvious from the start that you are seeking to

gain a deeper understanding of what the data “could” mean

Sometimes there is no smoking gun….and that’s ok!