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Title: The Surgical Infection Prevention and Surgical Care Improvement Projects Where we started and where we


1
The Surgical Infection Preventionand Surgical
Care Improvement ProjectsWhere we started and
where were going
Dale W. Bratzler, DO, MPH QIOSC Medical
Director Oklahoma Foundation for Medical Quality
2
Why focus on surgical quality?
  • 30 million major operations each year in the US
  • Despite advances in surgical and anesthesia
    technique and improvements in perioperative care,
    variations in outcomes for patients having
    surgery are well known

3
Why focus on surgical quality
  • Patients who experience a postoperative
    complication have dramatically increased hospital
    length of stay, hospital costs, and mortality
  • On average, the length of stay for patients who
    have a postoperative complication is 3 to 11 days
    longer

4
Consequences of Surgical Complications
  • Dimick and colleagues demonstrated increased
    costs
  • infectious complications was 1,398
  • cardiovascular complications 7,789
  • respiratory complications 52,466
  • thromboembolic complications 18,310.

Dimick JB, et al. J Am Coll Surg 2004199531-7.
5
Impact of Complications on Survival
Khuri and colleagues demonstrated that,
independent of preoperative patient risk, the
occurrence of a 30-day complication reduced
median patient survival by 69.
Khuri SF, et al. Ann Surg 2005242326-41.
6
Who Pays for Surgical Complications?
Hospital Reimbursement Costs of care Profit Profit margin
14266 (uncomplicated) 10978 3288 23.0
21911 (complicated) 21156 755 3.4
Complications were always associated with an
increase in costs to healthcare payors
complications were associated with an average
increase in payment of 7645 (54) per patient.
Dimick JB, et al. Who pays for poor surgical
quality? Building a business case for quality
improvement. J Am Coll Surg. 2006202933-7.
7
Medicare Surgical Infection Prevention (SIP)
Project Objective
  • To decrease the morbidity and mortality
    associated with postoperative infection in the
    Medicare patient population

8
Quality IndicatorsNational Surgical Infection
Prevention Project
  • Proportion of patients with antibiotic initiated
    within 1 hour before surgical incision
  • Proportion of patients who receive prophylactic
    antibiotics consistent with current
    recommendations
  • Proportion of patients whose prophylactic
    antibiotics were discontinued within 24 hours of
    surgery end time

9
Efficacy Of Prophylaxis Is Independent Of The
Specific Antibiotic
Penicillin, 40,000 U
Erythromycin, 0.1 mg/Kg
Control
Control
Staph Penicillin
Staph Erythromycin
Chloramphenicol, 0.1 mg/Kg
Tetracycline, 0.1 mg/Kg
Lesion Size, mm (24 Hours)
Control
Control
Staph Chloramphenicol
Staph Tetracycline
Age of Lesion at Antibiotic Injection (Hours)
Burke JF. Surgery. 196150161.
10
Clin Infect Dis. 2007 449217.
11
Clin Infect Dis. 2007 449217.
12
Discontinuation of Prophylaxis
  • Numerous clinical trials have compared short-term
    to long-term antimicrobial prophylaxis
  • Many compared single-dose prophylaxis to multiple
    dose prophylaxis
  • Wide variety of operations using a wide variety
    of antimicrobial agents
  • Infection rates are the same regardless of
    duration of prophylaxis
  • Prolonged prophylaxis has been associated with
    higher rates of infections with resistant
    organisms (when infection occurs). Prolonged
    prophylaxis only changes the flora it does not
    lower infection rates.

Prolonged prophylaxis is a patient safety issue.
13
Conclusions One-dose antibiotic prophylaxis did
not lead to an increase in rates of surgical site
infection and brought a monthly savings of 1980
considering cephazolin alone. High compliance to
1-dose prophylaxis was achieved through an
educational intervention encouraged by the
hospital director and administrative measures
that reduced access to extra doses.
Arch Surg. 20061411109-1113.
14
Although it did not reach statistical
significance, the timing of the administration of
the first dose of an antibiotic after incision
seems to be the most important prophylaxis
parameter. Multiple postoperative dosing did not
contribute to reduction of the incidence of SSI.
We strongly recommend that intervention programs
on surgical prophylaxis focus on timely
administration of the prophylactic antibiotic.
Clin Infect Dis. 2007 449217.
15
http//www.aaos.org/about/papers/advistmt/1027.asp
Recommendation 3 Duration of prophylactic
antibiotic administration should not exceed the
24-hour post-operative period. Prophylactic
antibiotics should be discontinued within 24
hours of the end of surgery. Medical literature
does not support the continuation of antibiotics
until all drains or catheters are removed and
provides no evidence of benefit when they are
continued past 24 hours.
16
http//www.sts.org/sections/aboutthesociety/practi
ceguidelines/antibioticguideline/
Conclusions The duration of antibiotic
prophylaxis should not be dependent on indwelling
catheters of any type. There is evidence
indicating that antibiotic prophylaxis of 48
hours duration is effective. There is some
evidence that single-dose prophylaxis or 24-hour
prophylaxis may be as effective as 48-hour
prophylaxis, but additional studies are necessary
before confirming the effectiveness of
prophylaxis lasting less than 48 hours. There is
no evidence that prophylaxis administered for
longer than 48 hours is more effective than a
48-hour regimen.
17
Antibiotic Recommendation Sources
  • American Society of Health System Pharmacists
  • Infectious Diseases Society of America
  • The Hospital Infection Control Practices Advisory
    Committee
  • Medical Letter
  • Surgical Infection Society
  • Sanford Guide to Antimicrobial Therapy
  • The Johns Hopkins Guide
  • Society of Thoracic Surgeons

18
Recent Guidelines
19
Recent Guidelines
20
Recently Updated Antibiotic Recommendations
Surgery Type Antimicrobial recommendations
Hip or knee arthroplasty Preferred Cefazolin or cefuroxime If patient high risk for MRSA Vancomycin Beta-lactam allergy Vancomycin or clindamycin
Cardiac or vascular Preferred Cefazolin or cefuroxime If patient high risk for MRSA Vancomycin Beta-lactam allergy Vancomycin or clindamycin
For the purposes of national performance
measurement a case will pass the antibiotic
selection performance measure if vancomycin is
used for prophylaxis (in the absence of a
documented beta-lactam allergy) if there is
physician documentation of the rationale for
vancomycin use (effective for July 2006
discharges).
Bratzler DW, Hunt DR. The Surgical Infection
Prevention and Surgical Care Improvement
Projects national initiatives to improve
outcomes for patients having surgery. Clin Infect
Dis. 200643322-30.
21
Recently Updated Antibiotic Recommendations
(continued)
Surgery Type Antimicrobial recommendations
Hysterectomy Cefotetan, cefazolin, cefoxitin, cefuroxime, or ampicillin-sulbactam Beta-lactam allergy Clindamycin gentamicin or fluoroquinolone or aztreonam Metronidazole gentamicin or fluoroquinolone Clindamycin monotherapy
Colorectal Neomycin erythromycin base neomycin metronidazole Cefotetan, cefoxitin, cefazolin metronidazole, or ampicillin-sulbactam Beta-lactam allergy Clindamycin gentamicin or fluoroquinolone or aztreonam Metronidazole gentamicin or fluoroquinolone
Ciprofloxacin, levofloxacin, gatifloxacin, or
moxifloxacin (effective for July 2006
discharges). For the purposes of national
performance measurement, a case will pass the
antibiotic selection indicator if the patient
receives oral prophylaxis alone, parenteral
prophylaxis alone, or oral prophylaxis combined
with parenteral prophylaxis.
Bratzler DW, Hunt DR. The Surgical Infection
Prevention and Surgical Care Improvement
Projects national initiatives to improve
outcomes for patients having surgery. Clin Infect
Dis. 200643322-30.
22
Antibiotics for Colorectal Surgery
  • Ertapenem will be added to the acceptable
    antibiotics for October discharges
  • Oral antibiotic prophylaxis alone will no longer
    pass the performance measure

23
National SurveillanceAntimicrobial Prophylaxis
24
Antibiotic Timing Related to Incision Where we
started in 2001
Bratzler DW, Houck PM, et al. Arch Surg.
2005140174-182.
25
Discontinuation of Antibiotics
Patients were excluded from the denominator of
this performance measure if there was any
documentation of an infection during surgery or
in the first 48 hours after surgery.
Bratzler DW, Houck PM, et al. Arch Surg.
2005140174-182.
26
Reporting Hospitals (Voluntary)Surgical
Infection Prevention Project
27
Surgical Infection PreventionHospital Voluntary
Self-Reporting, Qtr. 1, 2006
Based on medical record abstraction from the
charts of patients discharged in the 1st quarter
of 2006. Benchmark rates were calculated for all
HQA reporting hospitals in the US (N3247) based
on discharges during the 1st quarter of 2006
using the Achievable Benchmarks of CareTM
methodology (http//main.uab.edu/show.asp?durki14
527).
243 Texas hospitals voluntarily reporting (Qtr 1,
2006).
28
Antibiotic practices that have been shown to
reduce the risk of SSI.
  • Administration of the antibiotic dose just before
    incision
  • Antibiotic selection for the common organisms to
    be encountered
  • Appropriate dose adjustment based on patient
    weight
  • Redosing the patient in the operating room for
    long cases

29
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30
Surgical Care Improvement ProjectNational Goal
  • To reduce preventable surgical morbidity and
    mortality by 25 by 2010

31
SCIP Steering Committee
  • Centers for Medicare Medicaid Services
  • Centers for Disease Control and Prevention
  • Department of Veterans Affairs
  • Institute for Healthcare Improvement
  • Joint Commission on Accreditation of Healthcare
    Organizations
  • American College of Surgeons
  • American Hospital Association
  • American Society of Anesthesiologists
  • Association of peri-Operative Registered Nurses
  • Agency for Healthcare Research and Quality

32
Surgical Care Improvement Project (SCIP)
  • Preventable Complication Modules
  • Surgical infection prevention
  • Cardiovascular complication prevention
  • Venous thromboembolism prevention

33
Surgical Care Improvement ProjectPerformance
measures - Process
  • Surgical infection prevention
  • Antibiotics
  • Administration within one hour before incision
  • Use of antimicrobial recommended in guideline
  • Discontinuation within 24 hours of surgery end
  • Glucose control in cardiac surgery patients
  • Proper hair removal
  • Normothermia in colorectal surgery patients

34
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35
Furnary et al. Ann Thorac Surg 199967352
36
Pre-operative shaving
  • Shaving the surgical site with a razor induces
    small skin lacerations
  • potential sites for infection
  • disturbs hair follicles which are often colonized
    with S. aureus
  • Risk greatest when done the night before
  • Patient education
  • be sure patients know that they should not do you
    a favor and shave before they come to the
    hospital!

37
Temperature Control
  • 200 colorectal surgery patients
  • control - routine intraoperative thermal care
    (mean temp 34.7C)
  • treatment - active warming (mean temp on arrival
    to recovery 36.6C)
  • Results
  • control - 19 SSI (18/96)
  • treatment - 6 SSI (6/104), P0.009

Kurz A, et al. N Engl J Med. 1996. Also Melling
AC, et al. Lancet. 2001. (preop warming)
38
Cardiovascular Complication Prevention
39
Prevention of Cardiac EventsIntroduction
  • As many as 7 to 8 million Americans that undergo
    major noncardiac surgery have multiple cardiac
    risk factors or established coronary artery
    disease
  • More than 1 million cardiac events annually
  • Myocardial ischemia either clinically occult or
    overt confers a 9 - fold increase in risk of
    unstable angina, nonfatal myocardial infarction,
    and cardiac death

Schmidt M, et al. Arch Intern Med.
200216263-69. Mangano DT, et al. N Engl J Med.
19963351713-1720. Selzman CH, et al. Arch Surg.
2001136286-290.
40
Surgical Care Improvement ProjectPerformance
measure - Process
  • Perioperative cardiac events
  • Perioperative beta blockers in patients who are
    on beta blockers prior to admission

41
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42
http//www.acc.org/clinical/guidelines/perio/perio
betablocker.pdf
43
Venous Thromboembolism Prevention
44
Prevention of Venous Thromboembolism
  • Recent estimates show that
  • more than 900,000 Americans suffer VTE each year
  • about 400,000 of these being DVT
  • About 500,000 being manifest as PE
  • In about 300,000 cases, PE proves fatal it is
    the third most common cause of hospital-related
    deaths in the United States.

Heit JA, Cohen AT, Anderson FA on behalf of the
VTE Impact Assessment Group. Abstract American
Society of Hematology Annual Meeting, 2005.
45
National Body Position Statements
  • Leapfrog1
  • PE is the most common preventable cause of
    hospital
  • death in the United States
  • Agency for Healthcare Research and Quality
    (AHRQ)2
  • Thromboprophylaxis is the number 1 patient
    safety practice
  • American Public Health Association (APHA)3
  • The disconnect between evidence and execution
    as it
  • relates to DVT prevention amounts to a
    public health crisis.
  1. The Leapfrog Group Hospital Quality and Safety
    Survey. Available at www.leapfrog.medstat.com/pdf
    /Final/doc
  2. Shojania KG, et al. Making Healthcare Safer A
    Critical Analysis of Patient Safety Practices.
    AHRQ, 2001. Available at www.ahrq.gov/clinic/ptsa
    fety/
  3. White Paper. Deep-vein thrombosis Advancing
    awareness to protect patient lives. 2003.
    Available at www.alpha.org/ppp/DVT_White_Paper.pd
    f

46
Acquired Risk Factors
Risk Factor Attributable Risk
Hospitalization/Nursing home 61.2
Active malignant neoplasm 19.8
Trauma 12.5
CHF 11.8
CV catheter 10.5
Neurologic disease with paresis 8.2
Superficial vein thrombosis 4.3
Varicose veins/stripping 6
Many others.
47
Thromboprophylaxis Use in Practice 1992-2002
Prophylaxis Patient Group Studies
Patients Use (any) Orthopedic surgery
4 20,216 90 (57-98)
General surgery 7 2,473
73 (38-98) Critical care
14 3,654 69 (33-100)
Gynecology 1 456
66 Medical patients 5
1,010 23 (14-62)
48
Surgical Care Improvement ProjectPerformance
measures - Process
  • Prevention of venous thromboembolism
  • Proportion who have recommended VTE prophylaxis
    ordered
  • Proportion who receive appropriate form of VTE
    prophylaxis (based on ACCP Consensus
    Recommendations) within 24 hours before or after
    surgery

49
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50
ACCP Guidelines for VTE Prevention
Geerts WH, et al. CHEST. 2004126338S-400S.
51
Public Accountability and SCIP
52
Hospital Public Reporting P4R
0.4 Incentive
98.3 of PPS hospitals now reporting
53
Deficit Reduction Act of 2005
For purposes of clause (i) for fiscal year 2007
and each subsequent fiscal year, in the case of a
subsection (d) hospital that does not submit, to
the Secretary in accordance with this clause,
data required to be submitted on measures
selected under this clause with respect to such
a fiscal year, the applicable percentage increase
under clause (i) for such fiscal year shall be
reduced by 2.0 percentage points. The Secretary
shall expand, beyond the measures specified under
clause (vii)(II) and consistent with the
succeeding subclauses, the set of measures that
the Secretary determines to be appropriate for
the measurement of the quality of care furnished
by hospitals in inpatient settings. The
Secretary shall report quality measures of
process, structure, outcome, patients'
perspectives on care, efficiency, and costs of
care that relate to services furnished in
inpatient settings in hospitals on the Internet
website of the Centers for Medicare Medicaid
Services.
54
Deficit Reduction Act 2005Final Inpatient
Prospective Payment System Rule
  • Rules increase requirements
  • 21 measures (8-AMI, 7-Pneumonia, 4-Heart failure,
    2-Surgical Infection)
  • Though reporting is voluntary, failure to report
    results in loss of 2 of the Medicare Annual
    Payment Update

Federal Register. August 18, 2006.
55
OPPS RuleFinal Rule Posted on November 1, 2006
  • Expands required measures for hospital public
    reporting
  • 21 current measures
  • Adds
  • SCIP Infect 2 (antibiotic selection)
  • SCIP VTE 1 and 2
  • HCAHPS (consumer satisfaction)
  • Three new CMS 30-day mortality measures for AMI,
    HF, and Pneumonia (based on CMS analysis of
    Medicare fee-for-service claims data)

56
Hospital Acquired Infections (provisions of the
Deficit Reduction Act) In order to manage the
costs associated with Hospital Acquired
Infections, the DRA requires the Secretary to
identify, by October 1, 2007, at least two
conditions that are o High cost or high volume
or both o Result in a DRG that has a higher
payment when present as a secondary diagnosis
o Could have been reasonably prevented through
the application of evidence based guidelines
The IPPS proposed that for discharges on or
after October 1, 2008, that have one of the two
selected conditions as a secondary diagnosis that
was not present at admission will be paid as if
the secondary diagnosis was not present.
Therefore any charges associated with the
infection would not be paid.
57
Deficit Reduction Act - 2005
  • the Secretary is directed to begin phasing out
    payment increases associated with complications
    of care

Remember who pays for surgical complications
58
Deficit Reduction Act 2005Pay for performance
  • . the Secretary is directed to develop a plan
    to implement a value-based purchasing program
    based on the expanded measure set for which
    hospitals will submit data starting in FY 2007.
    The program will begin implementation in FY 2009
    (2008).

59
Surgical Care Improvement Project Why?
  • Medicare could prevent up to
  • 13,027 perioperative deaths
  • 271,055 surgical complications

Major surgical cases
60
Preliminary SCIP DataQtr. 1, 2005
National sample of 19, 497 Medicare patients. The
charts were independently abstracted by the CMS
CDAC.
61
SCIP Baseline AntibioticsPreliminary National
Data
Abx 1 hour Guideline Abx Abx stopped lt 24 hours
All operations 67.8 88.0 55.2
Cardiac 67.1 89.8 50.6
Vascular 63.1 85.8 58.1
Hip and knee 70.3 94.7 55.2
General colon 56.7 61.5 47.0
Hysterectomy 72.6 71.7 79.4
62
SCIP Baseline VTE ProphylaxisPreliminary
National Data
Appropriate Prophylaxis Ordered Appropriate Prophylaxis Received
All operations 78.3 76.1
Neurosurgery 93.9 92.8
Spinal surgery 96.6 96.5
General surgery 53.7 51.0
Gyn surgery 72.2 70.9
Urologic surgery 84.1 83.5
Hip replacement 91.0 89.4
Knee replacement 93.7 90.9
63
Summary
  • As the SIP project is expanded into the new
    Surgical Care Improvement Project we need to find
    ways to make evidence-based processes of care
    routine
  • We have to quit relying on memory to ensure high
    quality care
  • Recognize that there is now a national commitment
    to improving outcomes for surgical patients

64
www.medqic.org/scip
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