Collaboratives Demonstrate Gains in Fighting Surgical Infections

May 1, 2005

Collaboratives Demonstrate Gains in Fighting Surgical Infections

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

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

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

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
  • 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
  • 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

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
  • 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

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
  • 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

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

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.