Collaboratives Demonstrate Gains in Fighting Surgical Infections
By Kelly M. Pyrek
In the two years since a national campaign was launched to help fight surgical site infections (SSIs), several hundred hospitals are successfully implementing clinical processes to prevent SSIs, one of the leading causes of hospital-associated infections (HAIs). These facilities have been restructuring their protocols so that surgical patients are administered antibiotics within 60 minutes before incision an effort being promoted by local Quality Improvement Organizations (QIOs) of the Centers for Medicare and Medicaid Services (CMS).
This campaign becomes particularly important in light of a recent study in the Archives of Surgery, in which researchers discovered that only a little more than half of Medicare beneficiaries undergoing major surgery received antibiotics in the hour before incision. The effectiveness of antimicrobials administered shortly before skin incision for the prevention of surgical site infections was established in the 1960s and has been repeatedly demonstrated since. However, despite evidence of effectiveness use is often suboptimal, researchers said in the study, Use of Antimicrobial Prophylaxis for Major Surgery, Baseline Results From the National Surgical Infection Prevention Project.
Our study reveals a huge opportunity for hospitals to reduce the human and financial costs of surgical infections, says Dale Bratzler, DO, MPH, lead author of the study and principal clinical coordinator at the Oklahoma Foundation for Medical Quality. Bratzler is president of the American Health Quality Association, which represents the national network of QIOs that work under contract to Medicare to improve care in healthcare facilities. Researchers collected data for the study in 2001 as a baseline for the launch of the Surgical Infection Prevention Project (SIP), jointly sponsored by CMS and the Centers for Disease Control and Prevention (CDC). Bratzler adds that the SIP is based on past experience the CDC had gained from ongoing national surveillance for SSIs and CMSs ongoing work to reduce SSIs through its QIOs.
SSIs are a patient-safety issue and a public-health problem that we can prevent, says Dr. Bonnie Zell, senior advisor on patient safety and healthcare quality for the CDC. However, we do need partners to put our guidelines into practice, and thats what this project is about its about putting infection prevention into the hands of doctors taking care of patients, and developing systems of care that make it easier to follow the recommended steps to preventing SSIs. Its a good example of how government agencies, like the CDC and CMS, are taking combined expertise and putting it into action to address an important public-health problem. Dr. David Hunt, medical officer for the Quality Improvement Group at CMS, comments, There are substantial opportunities to improve basic processes of care that will impact the safety of our patients. For CMS, the information coming out of the SIPs also helps to validate the value of our QIOs as agents for change.
In the Archives of Surgery article, researchers report the results of their analysis of medical records from 2,965 acute-care hospitals throughout the United States, involving a random sample of 34,133 Medicare inpatients undergoing major surgeries during 2001. Surgical procedures studied for this project included coronary artery bypass graft (CABG), cardiac, colon, hip and knee arthroplasty, abdominal and vaginal hysterectomy, and selected vascular surgery procedures. The researchers found that 55.7 percent of these patients received antibiotics in the recommended timeframe of one hour before incision, 92.6 percent received the correct antibiotic, and 40.7 percent of patients had antibiotics discontinued within 24 hours following surgery to limit resistance to antibiotics.
The CDC reports that SSIs are the second most common cause of HAIs. There are about 15 million inpatient surgeries performed each year in U.S. hospitals, and of these, about 300,000 patients develop surgical site infections at an estimated cost of $1.5 billion.
Experts say that SSIs are a major cause of mortality and morbidity among hospitalized patients. Studies have shown that compared to similar risk patients undergoing the same surgery, a patient who develops an SSI is twice as likely to die, up to six times more likely to require re-admission, and likely to stay in the hospital twice as long. For major orthopedic or cardiac surgery, the costs of these complications may range from $30,000 to $50,000.
With these statistics in mind, in late 2002, as part of the SIP project, QIOs skilled in helping medical institutions redesign systems of care began providing technical assistance to hospitals in every state. Typically, QIOs bring together surgical teams from a number of hospitals for a series of training sessions aimed at incorporating infection prevention into treatment protocols. QIOs in 32 states report hospitals taking part in this training have shown significant improvement. For example, 26 hospitals participating in California increased the proportion of surgical patients receiving antibiotics within one hour of incision from 73.8 percent to 84.3 percent. In Colorado, 16 hospitals increased the proportion receiving antibiotics within one hour of incision from 62 percent to 88 percent. In Maryland, 16 hospitals went from 72 percent to 91.9 percent. In New Mexico, 19 hospitals went from 47.6 percent to 68 percent. In Texas, 42 hospitals went from 61 percent to 84 percent.
Individual hospitals often had significant results. For example, Leesburg Regional Medical Center in Florida went from 19.3 percent to 92 percent in administration of antibiotics in the hour before incision. Glen Cove Hospital in New York went from 43 percent in July 2003 to 100 percent in early 2004. By improving antibiotic administration and timing, Mercy Health Center in Oklahoma performed 400 surgeries without infections, four times its rate before participating in a QIOled training.
The Surgical Infection Prevention Project (SIP) shows what hospitals can accomplish if they work with QIOs or learn from other institutions that have succeeded, Bratzler emphasizes. Reducing surgical infections is often not expensive: costs are usually recovered through shorter hospital stays. What it takes is commitment to change and to provide the right care.
In Bratzlers study, medical records were examined to determine if the use of antimicrobials met three parameters of published guidelines for their use to prevent SSIs: whether they were given within one hour before the surgical incision; the selection of safe and effective antimicrobials consistent with current published guidelines; and their discontinuation 24 hours after surgery when the patient is no longer receiving a benefit.
Overall, 55.7 percent of patients received prophylactic antimicrobials during the 60 minutes before incision, the authors write. Prior studies have demonstrated that timing is critical to the effectiveness of prophylaxis, and current guidelines recommend dosing within one hour before incision. It is of interest that 9.6 percent of the patients in our assessment received their first dose more than four hours after incision when little if any benefit would be expected based on these previously published guidelines.
The researchers add, Most (92.6 percent) of the patients in this assessment received a prophylactic antimicrobial regimen consistent with current guidelines. However, only 78.7 percent received regimens that were limited to the recommended agents, suggesting that a substantial amount of antimicrobials are used unnecessarily.
Bratzler and colleagues say they are concerned about antimicrobial resistance. Our data suggest that vancomycin continues to be used excessively for surgical prophylaxis, the researchers emphasize. In addition, 59.3 percent of patients received prophylaxis for more than 24 hours after the end of surgery. There is evidence that use of new, broad-spectrum antimicrobials and prolonged use of antimicrobials can promote antimicrobial-resistant bacteria and increase the incidence of antibiotic-associated complications, according to Bratzlers study.
A longer duration of antibiotic administration promotes antibioticresistant bacteria and this causes antibiotics to be less effective, Zell explains. This is a significant public-health problem because currently, more than 70 percent of bacteria that cause HAIs are resistant to at least one of the drugs commonly used to treat them. Someone who is infected with resistant bacteria is more likely to have a longer hospital stay and require treatment with a second- or third-choice drug. These drugs tend to be less effective, more toxic, and more expensive. By stopping antibiotics within 24 hours after surgery is complete, we can decrease the development of antibiotic resistance. In terms of SSIs, by taking the steps we have outlined in this study, of ensuring appropriate antibiotic selection, timing and duration, we estimate we can prevent 40 percent to 60 percent of SSIs. However, it is our goal to prevent them all. The CDC is concerned about the problem of antibiotic resistance and the role it plays in SSIs and HAIs, and this is one of the many projects we are working on to addressing these problems. Substantial opportunities remain to improve the use of prophylactic antimicrobials for patients undergoing major surgery, Bratzler adds.
Achieving high rates of performance for appropriate antimicrobial prophylaxis to prevent SSIs will require the development of systems in which the knowledge from years of research and recommendation from clinical practice guidelines are routinely incorporated into practice.
Bratzler adds that his studys findings represent the first step in a number of measures designed to improve surgical care by encouraging QIOs to work closely with hospitals across the country. I think this project highlights how national organizations can work together through local quality initiatives to improve quality of care. Many hospitals are voluntarily collecting this information and have started reporting their own data on antibiotic use to Medicare. Right now, more than 900 hospitals nationwide are submitting data and their quality of care for these performance measures to prevent SSIs. The ultimate outcome we would like to see from this project is a reduction in the number of SSIs.
Participating in a statewide SIP collaborative, California hospitals measurably decreased surgical infections by improving rates of appropriate antibiotic administration to surgical patients. Overall, teams from 26 participating hospitals decreased SSI rates by an average of 10.7 percent across three measures in just over a year through their voluntary participation in the collaborative, led by Lumetra, Californias Medicare QIO. Between April 2003 and April 2004, the participating hospitals teamed with Lumetras experts, sharing data and expertise, to decrease surgical infections through collaborative learning processes and implementing better methods of care.
The collaborative focused on three infection-prevention quality measures: prophylactic antibiotic selection for surgical patients; prophylactic antibiotics received within one hour prior to surgical incision; and prophylactic antibiotics stopped within 24 hours of the surgerys completion. The teams made notable progress, including:
- Increasing from 91.3 percent to 97.4 percent the proportion of surgical patients receiving appropriate prophylactic antibiotics
- Increasing from 73.8 percent to 84.3 percent the proportion of surgical patients receiving prophylactic antibiotic within one hour prior to surgical incision
- Increasing from 46.0 percent to 61.7 percent the proportion of surgical patients with prophylactic antibiotics discontinued within 24 hours after surgery end time
Teams from16 hospitals in Colorado participated with the Colorado Foundation for Medical Care (CFMC) in the Surgical Infection Prevention Collaborative. Between March 2003 and March 2004, participating hospital teams implemented, tested and tracked changes in prophylactic antibiotic administration. Their progress included:
- Increasing from 77 percent to 94 percent the proportion of surgical patients receiving appropriate prophylactic antibiotics
- Increasing from 62 percent to 88 percent the proportion of surgical patients receiving prophylactic antibiotic within one hour prior to surgical incision
- Increasing from 57 percent to 67 percent the proportion of surgical patients with prophylactic antibiotics discontinued within 24 hours after surgery end time
Several facilities in Texas also saw significant results from participation in local collaboratives. Working with the Texas Medical Foundation (TMF), Medicares QIO for Texas, Methodist Dallas Medical Center Neurosurgery and Orthopedic Surgery departments were able to dramatically boost performance on five of six SIP quality indicators and to achieve 95 percent compliance in five out of six SIP indicators.
Baseline rates and rates at re-measurement included:
- Appropriate prophylactic antibiotics: from 68.3 percent to 98.1 percent
- Discontinuation of antibiotics: from 48.8 percent to 75.0 percent
- Normothermia: from 78.6 percent to 96.2 percent
- Not shaving: from 73.8 percent to 100 percent
- Re-dosing for prolonged surgeries: from 2 percent to 100 percent
- On-time antibiotics: from 97.6 percent to 96.2 percent
At the start of the project, the hospital shared SSI rates with each surgical department, identified barriers, and addressed issues with evidence from the literature and through discussion. After the nine-month effort, not only were the measures improved, but there was increased awareness of measures with the anesthesia group, surgery, and staff.
The Physicians Centre, a 16-bed hospital in Bryan, Texas, has been participating in TMFs SIP collaborative since August 2003, and is working to improve care for patients having total joint replacements or hysterectomies. An orthopedic surgeon and a gynecologist serve as clinical champions and work with a multi-disciplinary team to improve care processes. The team used rapid plan-do-study-act (PDSA) cycles to develop and implement a new pre-printed order set that addressed all of the performance measures. PDSA cycles were also used to standardize IV antibiotic administration as the patient enters the operating room. To maintain perioperative patient normothermia, protocols for using patient warming devices are currently being tested.
They had the following results:
- Antibiotics administered within one hour prior to surgery: 66 percent to 95 percent
- Use of recommended antibiotics: 76.6 percent to 100 percent
- Antibiotics discontinued within 24 hour of surgery: 62.8 percent to 85 percent
- Perioperative normothermia: 39.4 percent to 90 percent
- Patients receiving 80 percent supplemental oxygen: 0 percent to 90 percent
- Surgical site not shaved: 52.1 percent to 100 percent
The hospitals SIP team has overcome barriers such as difficulty in finding a time to meet with surgeons, documentation problems, and one surgeons reluctance to discontinue antibiotics within 24 hour of surgery. Team leader Chris Allen, RN, CIC, reports that, The surgeons are enthusiastic about the project and the team is motivated and works well together. The team will be monitoring their performance measures monthly to ensure their gains are maintained.
Memorial Hermann The Woodlands (MHTW) Hospital also is participating in TMFs SIP collaborative. They began piloting improvement methods with one orthopedic surgeon on his hip and knee arthroplasty cases. The goal of their project was to improve the selection and timing of prophylactic antibiotics, then involve other orthopedic surgeons. To accomplish their goal, communication about the project to physicians and hospital staff was essential; these methods implemented include:
- Use storyboards in the OR and nursing areas. Rotate them to keep interest alive.
- Conduct in-services at department meetings and at varied times in hospital classrooms.
- Make SIP a part of Nursing Skills Day.
- Use Hospital Week, Nurses Week, or any similar event to promote SIP guidelines.
- Present data at every medical staff meeting.
- Provide surgeons with scientific information supporting SIP guidelines.
- Encourage nurses to discuss with physicians their antibiotic orders.
- Get feedback from the CEO, and use his name often.
- Use external media to stimulate interest.
Regarding the latter method, MHTWs project was covered by News-24 in Houston. According to employee Diane Maxwell, The TV news coverage made people recognize that this was a real, tangible process for improved patient outcomes. As MHTW plans to spread improvement to additional specialties, they are recruiting additional physician champions and are conducting in-services to hospital staff who will become involved in the project. For arthroplasties, MHTW has reached 100 percent compliance on appropriate selection of an antibiotic and on administering the antibiotic within one hour prior to surgery. Discontinuation of antibiotics within 24 hours after surgery continues to be a challenge, and the physician champion is talking to other surgeons about this issue.
In New Jersey, led by PRONJ, the QIO of New Jersey, Inc., under contract with CMS, hospitals used three quality measures to gauge improvement: the number of patients who received appropriate prophylactic antibiotics; the number of patients who received prophylactic antibiotics within one hour of surgical incision; and the number of patients in whom prophylactic antibiotics were discontinued within 24 hours of surgery end time. In New Jersey, rates for all of the surgical infection measures improved from the baseline period of the project (April 2001 to September 2001) to the first quarter of 2004.
The rates for the second and third measures increased to 70.33 percent from 36.1 percent and 67.05 percent from 40.30 percent, respectively, reflecting relative improvements of approximately 50 percent from baseline. Rates for the first measure improved to 87.36 percent from 86.70 percent, a 4.95 percent relative improvement.
PRONJ has supported the sharing of information among New Jersey hospitals to decrease SSIs. For example, one hospital created a form that assisted its surgeons and other members of the perioperative team in complying with recognized standards for prophylactic antibiotic selection, administration and timing. There was an 80.3 percent relative improvement in the average surgical infection prevention rate for the hospital from baseline to the first quarter of 2004. This tool was shared with other hospitals in a PRONJ-sponsored learning session.
Process measures to prevent post-operative infections in New Mexico have significantly improved as a result of the work of participating hospitals in the New Mexico Surgical Infection Prevention (SIP) Collaborative. Convening this quality improvement project from January through November 2003 was the New Mexico Medical Review Association, (NMMRA), under contract with CMS. Out of the eligible 42 New Mexico hospitals, 19 participated in the collaborative.
Focusing on process measure areas identified as highly effective in preventing SSIs, participating collaborative hospitals were able to, from 2002 to 2003:
- Increase their rate of administering prophylactic antibiotics within one hour prior to incision from 47.6 percent to 68 percent.
- Increase their rate of discontinuing prophylactic antibiotics within 24 hours of surgery end time from 27.6 percent to 47.9 percent
For the other effective preventative process measure of selecting appropriate antibiotic measures according to guidelines, rates were already high; collaborative participants achieved minimal improvement over the same time. Hospitals not participating in the collaborative actually decreased their rate of administering antibiotics within one hour of surgery from 61.9 percent to 50.8 percent, and achieved a minimal rate increase from 23.5 percent to 25.6 percent in the postsurgery discontinuation of antibiotics. Based on the national project baseline rates established by CMS in 2001, the work of the New Mexico SIP Collaborative participants was pivotal in the dramatic improvement of statewide rates of timely prophylactic antibiotic distribution:
- Rates of administering antibiotics within one hour of surgery increased from 38.5 percent to 62.7 percent
- Rates of discontinuing antibiotic within 24 hours of surgical end time increased from 29.2 percent to 40.9 percent
Again, state rates were already high for the other effective infection prevention process measure of selecting appropriate antibiotic measures according to guidelines, and minimal improvement was achieved. New Mexico SIP Collaborative participating hospitals attended three full-day learning sessions and an outcomes congress to learn best practices and share improvement methods in surgical infection prevention, which included:
- Disseminating guidelines/research findings to surgical and medical staff
- Displaying infection rates/policies/guidelines in operating rooms and physician lounges
- Providing monthly feedback to surgical staff on infection rates
- Standardizing delivery processes to ensure timely delivery of preoperative antibiotics to the holding area
- Creating visible reminders to give antibiotics on each case (e.g., brightly colored stickers)
- Reviewing and updating protocols
New England Baptist (NEB) Hospital in Boston, specializing in orthopedic surgery, started working in earnest with MassPRO in 2004, attending seven conferences for heart failure, pneumonia, surgical infection prevention (SIP) and quality improvement liaison meetings. As of the third quarter of 2004, NEB exceeded achievable benchmarks for SIP for all three measures. For antibiotics given within one hour before incision, NEB achieved 95 percent; for use of appropriate antibiotic, NEB achieved 98 percent; for discontinuing antibiotics within 24 hours, NEB achieved 87 percent.
Another Massachusetts hospital that is up-and-coming for breakthrough performance in SIP is Morton Hospital in Taunton. Morton started working with MassPRO in 2004, attending four SIP, pneumonia and heart failure collaborative meetings and Webex events. The MassPRO HCQIP Hospital Team presented at Mortons surgical grand rounds in November 2004, and since that time, Morton has worked closely with the team and reports that they have achieved 100 percent on antibiotics within one hour before incision.
As a result of its work with MassPRO, Baystate Medical Center (BMC) has increased its rate of on-time antibiotic administration for its surgical patients by 59 percent. Using what it learned as a participant in the SIP collaborative, BMC performed multiple small tests of change to overhaul its perioperative system, including the presentation of baseline data and evidence-based resources to surgical staff, the implementation of standardized administration and documentation processes, and the revision of order sets.
Using this model, BMC has also made improvements in other SIP indicators, including appropriate antibiotic selection and the discontinuation of antibiotic therapy within 24 hours. I know I can speak for Baystate Medical Center when I say that the changes which have taken place in our operating rooms before and after surgery have been a reflection of the impact MassPRO has had on improving patient care surrounding surgical infection prevention, says Richard M. Engelman, MD, chief of cardiac surgical research at Baystate Medical Center.
Bratzler D. Use of antimicrobial prophylaxis for major surgery, baseline results from the National Surgical Infection Prevention Project. Arch Surg. 2005;140:174-182.