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Perioperative Antibiotic Prophylaxis: What Anesthesia Needs To Know
Perioperative Antibiotic Prophylaxis: What Anesthesia Needs To Know
Outline
Science/History Consensus Oversight Results Process
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2/23/11
Infection Rates
Early 3.8% Preoperative 0.6% Perioperative 1.4% Postoperative 3.3%
14/369
15/441 1/41
Infections (%)
-3
-2
-1
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3 Measures:
Tiiming Correct Choice Duration of therapy
Timing: within 1 hr
vs 30 minvs 120 min consensus opinion not scientific proof Quality projects
No evidence >24 hrs offers benefit >24 hrs does inc resistance/ c diff
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Percent
40 30 20 10 0
0 12 061 60 -0 24 018 1 18 012 1 060 0 12 118 0 24 61 -1 2 >
2.7 1.2 4.3 20.3
Incision
18 124 0
>
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www.medqic.org/sip
CMS,CDC
Reduce nationally the incidence of surgical complications by 25% by 2010 (13,027 deaths, 271,055 complications)/yr Focus on
Surgical infection prevention Adverse cardiac events Prevention of DVT Post operative pneumonia
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0.8-2 million infections a year Average 7.5 additional days $130-$845 million per year Adds $2,734 - $26,019 per pt (average $3,000)
SI increase LOS
Excess costs
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more likely to spend time in an ICU 5 times as likely to be readmitted Have a mortality rate twice that of noninfected patients
An
U AP
re inc
as
t ed
% o2
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% Patients
Use of antimicrobial prophylaxis for major surgery: baseline results from the National Surgical Infection Prevention Project Arch Surg. 2005 Feb;140(2):174-82.
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Prophylactic Antibiotics
Antibiotics given for the purpose of preventing infection when infection is not present but the risk of post-operative infection is present
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Prophylactic Antibiotics
Questions
Which cases benefit? When should you start? Which drug should you use? How much should you give? How long should antibiotics be continued?
* 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).
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Prophylactic Antibiotics
Questions
Which cases benefit? When should you start? Which drug should you use? How much should you give? How long should antibiotics be continued?
60 50 40 30 20 10 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25
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Memorandum
DIVISION OF HEALT HCARE QUALITY TO: FROM: Associate Medical Director DATE: , 2006 , MD
SUBJECT: SCIP (Surgical Care Improvement Program) As part of the SCIP process, the medical record of PATIENT was reviewed. As eviden ced by the attached documentation , it appearsthat thepatient s prophylactic pre -operativeantibiotic w as: _____given greater than 1 hour prior to th e initial incisiontime, _____not re-dosed. _____given after the initial surgical incision. _X__not g iven at all ( no time of administration was documented) Pleaserememberthat current standard of practice is prophylactic pre -operative an tibiotic administration within 60 minutes p rior to the incision (Levaq uin and Vancomycin are within 120 minutes prior to theincision ). Re-dosing of antibiotics if the case extends beyond 3 hours when cefazolins are used Please contact me at 4 4326 if you have any questions. Thank you.
SIP: Prophylactic AB given < 60 M Prior to Incision Baystate Medical Center Springfield MA USA 100 Improved documentation
80
Ongoing 1:1 review of outliers
% Patients
60
Anesthesiologists to give Abs rates posted in OR
Ongoing Review
40 20
Pre op gives AB Initial education all staff, Rates adoped for monthly report to PI teams SIP starts
Anesthesiologist specific score card adopted for posting; Ongoing 1:1 review of outliers
0
Ap r-0 2 Ju n-0 Au 2 g -0 2 Oc t-0 De 2 c -0 Fe 2 b-0 Ap 3 r-0 3 Ju n-0 Au 3 g -0 3 Oc t-0 De 3 c -0 Fe 3 b-0 Ap 4 r-0 4 Ju n-0 Au 4 g -0 4 Oc t-0 De 4 c -0 Fe 4 b-0 Ap 5 r-0 5 Ju n-0 Au 5 g -0 5 Oc t-0 De 5 c -0 Fe 5 b-0 Ap 6 r-0 6 Ju n-0 Au 6 g -0 6
BMC Prophylaxis AB Timing (within 60 M of incision)
100
80
% Patients
60
40 20
0
Apr02 Jun- Aug- Oct- Dec- Feb- Apr02 02 02 02 03 03 Jun- Aug- Oct- Dec- Feb- Apr03 03 03 03 04 04 Jun- Aug- Oct- Dec- Feb- Apr04 04 04 04 05 05 Jun- Aug- Oct- Dec- Feb- Apr05 05 05 05 06 06 Jun- Aug- Oct- Dec- Feb06 06 06 06 07
60 40 20 0
Apr- Jun- Aug- Oct- Dec- Feb- Apr- Jun- Aug- Oct- Dec- Feb- Apr- Jun- Aug- Oct- Dec- Feb- Apr- Jun- Aug- Oct- Dec- Feb- Apr- Jun- Aug- Oct- Dec- Feb02 02 02 02 02 03 03 03 03 03 03 04 04 04 04 04 04 05 05 05 05 05 05 06 06 06 06 06 06 07
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How to do it
Electronic promptreference
Prophylactic Antibiotics
Questions
Which cases benefit? When should you start? Which drug should you use? How much should you give? How long should antibiotics be continued?
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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 2003
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**SURGERY
Last name: ____________________________ First name: ________________ MI: _______ Date of birth:______________ Physician: __________________ PCP:____________________ Surgery/procedure date:____/____/___ Time:__________ Hospital based PAE booked? YES: NO: If yes specify reason: ______________________________________________
PROCEDURE: __________________________________________________________________________________________
_________________________________________________________________________________ _________________________________________________________________________________
________________________________________________________________________________________________________ CONSENT: _____________________________________________________________________________________________
Type of Surgery
If No Penicillin Allergy
1 gm (<70Kg) 2 gm (>70 Kg) IV cefazolin or cefoxitin
If anaphylaxis to penicillin or Cephalosporin or documented high risk for resistant organism clindamycin IV 600 mg PLUS gentamicin IV 80 mg if pt wt < 70 K or 120 mg > 70 K vancomycin IV 1 gm IVPB PLUS gentamicin IV 80 mg if pt wt < 70 K or 120 mg > 70 K vancomycin IV 1 gm OR clindamycin IV 600 mg vancomycin IV 1 gm OR clindamycin IV 600 mg vancomycin IV 1 gm
Alternative
cefoxitin IV give 1 gm if wt < 70 Kg or 2 gm if wt > 70 kg cefazolin IV give 1 gm if wt < 70 Kg or 2 gm if wt > 70 kg cefazolin IV give 1 gm if wt < 70 Kg or 2 gm if wt > 70 kg cefazolin IV give 1 gm if wt < 70 Kg or 2 gm if wt > 70 kg cefazolin IV give 1 gm if wt < 70 Kg or 2 gm if wt > 70 kg cefazolin IV give 1 gm if wt < 70 Kg or 2 gm if wt > 70 kg levofloxacin 500 mg PO OR IV cefazolin IV give 1 gm if wt < 70 Kg or 2 gm if wt > 70 kg
clindamycin IV 600 mg PLUS gentamicin IV 80 mg if pt wt < 70 K or 120 mg > 70 K vancomycin IV 1 gm IVPB PLUS gentamicin IV 80 mg if pt wt < 70 K or 120 mg > 70 K vancomycin IV 1 gm IVPB PLUS gentamicin IV 80 mg if pt wt < 70 K or 120 mg > 70 K
DVT PROPHYLAXIS: (select chemical prophylaxis based on patient existing co-morbidities) Enoxaparin 40 mg subcutaneous x1 in Pre op Holding Unit. Hold for patients receiving epidural catheter Unfractionated Heparin 5000 units subcutaneous x1 in Pre op Holding Unit. Pneumatic compression device (if not lower extremity vascular procedure) in cases >30 minutes of general anesthesia HAIR REMOVAL Clip or None OTHER: Confirm Advanced Directives
PRE OPERATIVE MEDICATIONS: ________________________________________________________________________ _________________________________________________________________________________________________________ ________________________________________________________________________________________________________ Physician signature: ____________________________________________________________ Date: _____________________ H&P Dictated by________________ Date: ______ Where sent: ___________________ FAX COMPLETED AND SIGNED FORM TO PAE (413) 794 1856 OR (413) 794 4875
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60 40 20 0
Jul-04 Mar-04 Mar-05 Jul-05 May-04 May-05 Mar-06 May-06 Jan-04 Jan-05 Nov-04 Nov-05 Sep-04 Sep-05 Jan-06
Expanded pt populations
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Prophylactic Antibiotics
Questions
Which cases benefit? When should you start? Which drug should you use? How much should you give? How long should antibiotics be continued?
Quality Indicator #3
Proportion of patients whose prophylactic antibiotics were discontinued within 24 hours of surgery end time
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Discontinuation of Antibiotics
100
85.8 79.5 88 90.7
100
80
73.3
80
Cumulative Percent
Percent
60
40.7
50.7
60
40
26.2 22.6
40
20
20
0
-2 4 -3 6 -4 8 -6 0 -7 2 -8 4 le -9 6 >1 2 >2 4 >3 6 >4 8 >6 0 >7 2 >8 4 > 96 ss
12
or
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. 2005;140:174-182.
12 hours
single dose
Whenever compared, the shorter course
Colorectal Mixed GI Hysterectomy Gyn & GI Head & Neck Orthopedic Vascular Cardiac Total
3 4 3 1 3 4 3 __7__ 28
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Duration should not exceed 24-hour 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 past 24 hours
http://www.aaos.org/wordhtml/papers/advistmt/1027.htm
confidential
Gary Kanter, M.D. Associate Medical Director, Healthcare Quality Neal Seymour M.D. Vice Chairman Department of Surgery
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100
80
% Patients
60
40
20
Outcome
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st.dev. 0.39% 3.16% 2.77% 2.39% avg 2.00% 1.61% 1.23% 0.84% inhse 0.86%
1.13 %
Antibiotic prophylaxis is one (of many) methods for reducing SSI No evidence that antibiotics given after the operation prevent SSI There is evidence that increased use of antibiotics promotes antibiotic resistance
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!
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Infections (%)
Hair Removal
" Shaving the night before an operation -- a
significantly higher SI risk than either the use of depilatory agents or no hair removal " Do not remove hair unless it will interfere with the operation (Category IA) " If hair is removed, remove immediately before, with electric clippers (Category IA)
Three trials involving 3193 patients Shaving vs clipping More SSIs when people were shaved (Rate Ratio 2.02, 95%CI 1.21 to 3.36)
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Interventions
Razors removed from OR s Razors removed from most clinical areas Patients may use razors for personal hygiene Clippers in every OR
**SURGERY
Last name: ____________________________ First name: ________________ MI: _______ Date of birth:______________ Physician: __________________ PCP:____________________ Surgery/procedure date:____/____/___ Time:__________ Hospital based PAE booked? YES: NO: If yes specify reason: ______________________________________________
PROCEDURE: __________________________________________________________________________________________
________________________________________________________________________ _________ _________________________________________________________________________________ ALLERGIES: _______________________________________________________________________ ________________________________________________________________________ _________ ___________________________________________________________________ Patient states none
PRE OPERATIVE ORDERS include IV fluids, selected medications and laboratory tests including Type and Screen will be ordered according to Baystate Medical Center Preadmission Evaluation Guidelines. No additional laboratory requests are necessary. SPECIAL LABORATORY TESTS PER MD REQUEST:_________________________________________________________________
Type of Surgery
If No Penicillin Allergy
cefazolin or cefoxitin 1 gm (<70Kg) 2 gm (>70 Kg)
IV
If anaphylaxis to penicillin or Cephalosporin or documented high risk for resistant organism clindamycin IV 600 mg PLUS gentamicin IV 80 mg if pt wt < 70 K or 120 mg > 70 K vancomycin IV 1 gm IVPB PLUS gentamicin IV 80 mg if pt wt < 70 K or 120 mg > 70 K vancomycin IV 1 gm OR clindamycin IV 600 mg vancomycin IV 1 gm OR clindamycin IV 600 mg vancomycin IV 1 gm
Alternative
cefoxitin IV give 1 gm if wt < 70 Kg or 2 gm if wt > 70 kg cefazolin IV give 1 gm if wt < 70 Kg or 2 gm if wt > 70 kg cefazolin IV give 1 gm if wt < 70 Kg or 2 gm if wt > 70 kg cefazolin IV give 1 gm if wt < 70 Kg or 2 gm if wt > 70 kg cefazolin IV give 1 gm if wt < 70 Kg or 2 gm if wt > 70 kg cefazolin IV give 1 gm if wt < 70 Kg or 2 gm if wt > 70 kg levofloxacin 500 mg PO OR IV cefazolin IV give 1 gm if wt < 70 Kg or 2 gm if wt > 70 kg
clindamycin IV 600 mg PLUS gentamicin IV 80 mg if pt wt < 70 K or 120 mg > 70 K vancomycin IV 1 gm IVPB PLUS gentamicin IV 80 mg if pt wt < 70 K or 120 mg > 70 K vancomycin IV 1 gm IVPB PLUS gentamicin IV 80 mg if pt wt < 70 K or 120 mg > 70 K
DVT PROPHYLAXIS: (select chemical prophylaxis based on patient existing co-morbidities) Enoxaparin 40 mg subcutaneous x1 in Pre op Holding Unit. Hold for patients receiving epidural catheter Unfractionated Heparin 5000 units subcutaneous x1 in Pre op Holding Unit. Pneumatic compression device (if not lower extremity vascular procedure) in cases >30 minutes of general anesthesia
HAIR REMOVAL
Clip or
None
OTHER:
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SSI Surveilance
Surveillance
" List of patients sent to each surgeon, 30 days
post procedure 97% return rate (SASE, interoffice mailing) Self report: any post operative infection/ comments " Daily admissions with wound infection Review for surgical date and s/s infection " Daily microbiology reports of all + cultures reviewed for wound, fluid cultures, e.g joint aspirates Charts reviewed for NNIS criteria, surgical date and s/s infection
Investigation
NNIS criteria: ASA, Wound Class, Length of Procedure Presence of interventions
Antibiotic use Surgical prep and skin condition Implants Specific conditions of the patient Surgical environment Organism Surgical team
Cluster evaluation
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All infections reviewed for potential preventability using SCIP guidelines Reviewed using other criteria as well Review done by IC dept and fed back to multiple cmts (COI, SCIP, SPIT, SAQI) System level changes made when applicable Consistently, 50% of infections have a SCIP miss!!
information, tests, diagnoses Communication Hand offs Failure to recognize Failure to activate Failure to rescue
Improvement Tools
Systems Populations Cycles
of Change
Six Sigma, LEAN
PDSA,
Process
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Keys to Success
Persistence and reinforcement/high visibility Senior leader support Multidisciplinary cooperation & collaboration Willing to try changes and take a risk Develop reliable systems
Surveillance
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Background
>46,000
Cluster Investigation
Chart
review processing OR traffic Microbiology OR observations Link to specific OR? Link to specific practitioner? Link to Surgical Processing? Correct/timing of antibiotics?
Surgical
Standard
Soap Nail
Chlorhexidine/Alcohol
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Solution Chosen
Education Removal
of Product
Conclusion
There
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Lessons Learned
Involve all stakeholders Leave your stripes at the door Must have physician champions- credible Be humble BROAD shoulders Must work as team Small tests of change with frequent tempo Small pilot population Work within your culture Make the right thing the easy thing
Future
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Real Value
Provide Framework for success/quality Empower all providers Standardize Care Don t worry about credit
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