surgical infection prevention project team: anesthesia infectious disease pharmacy surgical services...
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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