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ByKelly M. Pyrek
In the two years since a nationalcampaign was launched to help fight surgical site infections (SSIs), severalhundred hospitals are successfully implementing clinical processes to preventSSIs, one of the leading causes of hospital-associated infections (HAIs). Thesefacilities have been restructuring their protocols so that surgical patients areadministered antibiotics within 60 minutes before incision an effort beingpromoted by local Quality Improvement Organizations (QIOs) of the Centers forMedicare and Medicaid Services (CMS).
This campaign becomes particularly important in light of arecent study in the Archives of Surgery,in which researchers discovered that only a little more than half of Medicarebeneficiaries undergoing major surgery received antibiotics in the hour beforeincision. The effectiveness of antimicrobials administered shortly beforeskin incision for the prevention of surgical site infections was established inthe 1960s and has been repeatedly demonstrated since. However, despite evidenceof effectiveness use is often suboptimal, researchers said in the study,Use of Antimicrobial Prophylaxis for Major Surgery, Baseline Results From theNational Surgical Infection Prevention Project.
Our study reveals a huge opportunity for hospitals toreduce the human and financial costs of surgical infections, says DaleBratzler, DO, MPH, lead author of the study and principal clinical coordinatorat the Oklahoma Foundation for Medical Quality. Bratzler is president of theAmerican Health Quality Association, which represents the national network ofQIOs that work under contract to Medicare to improve care in healthcarefacilities. Researchers collected data for the study in 2001 as a baseline forthe launch of the Surgical Infection Prevention Project (SIP), jointly sponsoredby CMS and the Centers for Disease Control and Prevention (CDC). Bratzler addsthat the SIP is based on past experience the CDC had gained from ongoingnational surveillance for SSIs and CMSs ongoing work to reduce SSIs throughits QIOs.
SSIs are a patient-safety issue and a public-health problemthat we can prevent, says Dr. Bonnie Zell, senior advisor on patient safetyand healthcare quality for the CDC. However, we do need partners to put ourguidelines into practice, and thats what this project is about itsabout putting infection prevention into the hands of doctors taking care ofpatients, and developing systems of care that make it easier to follow therecommended steps to preventing SSIs. Its a good example of how governmentagencies, like the CDC and CMS, are taking combined expertise and putting itinto action to address an important public-health problem. Dr. David Hunt, medical officer for the Quality ImprovementGroup at CMS, comments, There are substantial opportunities to improve basicprocesses of care that will impact the safety of our patients. For CMS, theinformation coming out of the SIPs also helps to validate the value of our QIOsas agents for change.
In the Archives of Surgery article,researchers report the results of their analysis of medical records from 2,965acute-care hospitals throughout the United States, involving a random sample of34,133 Medicare inpatients undergoing major surgeries during 2001. Surgicalprocedures studied for this project included coronary artery bypass graft(CABG), cardiac, colon, hip and knee arthroplasty, abdominal and vaginalhysterectomy, and selected vascular surgery procedures. The researchers found that 55.7 percent of these patientsreceived antibiotics in the recommended timeframe of one hour before incision,92.6 percent received the correct antibiotic, and 40.7 percent of patients hadantibiotics discontinued within 24 hours following surgery to limit resistanceto antibiotics.
The CDC reports that SSIs are the second most common cause ofHAIs. There are about 15 million inpatient surgeries performed each year in U.S.hospitals, and of these, about 300,000 patients develop surgical site infectionsat an estimated cost of $1.5 billion.
Experts say that SSIs are a major cause of mortality andmorbidity among hospitalized patients. Studies have shown that compared tosimilar risk patients undergoing the same surgery, a patient who develops an SSIis 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 orcardiac 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 theSIP project, QIOs skilled in helping medical institutions redesign systems ofcare began providing technical assistance to hospitals in every state.Typically, QIOs bring together surgical teams from a number of hospitals for aseries of training sessions aimed at incorporating infection prevention into treatment protocols. QIOs in 32 states report hospitalstaking part in this training have shown significant improvement. For example, 26hospitals participating in California increased the proportion of surgicalpatients receiving antibiotics within one hour of incision from 73.8 percent to84.3 percent. In Colorado, 16 hospitals increased the proportion receivingantibiotics within one hour of incision from 62 percent to 88 percent. InMaryland, 16 hospitals went from 72 percent to 91.9 percent. In New Mexico, 19hospitals went from 47.6 percent to 68 percent. In Texas, 42 hospitals went from61 percent to 84 percent.
Individual hospitals often had significant results. Forexample, Leesburg Regional Medical Center in Florida went from 19.3 percent to92 percent in administration of antibiotics in the hour before incision. Glen Cove Hospital in New York went from 43 percent in July2003 to 100 percent in early 2004. By improving antibiotic administration andtiming, Mercy Health Center in Oklahoma performed 400 surgeries withoutinfections, four times its rate before participating in a QIOled training.
The Surgical Infection Prevention Project (SIP) shows whathospitals can accomplish if they work with QIOs or learn from other institutionsthat have succeeded, Bratzler emphasizes. Reducing surgical infections isoften 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 todetermine if the use of antimicrobials met three parameters of publishedguidelines for their use to prevent SSIs: whether they were given within onehour before the surgical incision; the selection of safe and effectiveantimicrobials consistent with current published guidelines; and theirdiscontinuation 24 hours after surgery when the patient is no longer receiving abenefit.
Overall, 55.7 percent of patients received prophylacticantimicrobials during the 60 minutes before incision, the authors write. Priorstudies have demonstrated that timing is critical to the effectiveness ofprophylaxis, and current guidelines recommend dosing within one hour beforeincision. It is of interest that 9.6 percent of the patients in our assessmentreceived their first dose more than four hours after incision when little if anybenefit would be expected based on these previously published guidelines.
The researchers add, Most (92.6 percent) of the patients inthis assessment received a prophylactic antimicrobial regimen consistent withcurrent guidelines. However, only 78.7 percent received regimens that werelimited to the recommended agents, suggesting that a substantial amount ofantimicrobials are used unnecessarily.
Bratzler and colleagues say they are concerned aboutantimicrobial resistance. Our data suggest that vancomycin continues to beused excessively for surgical prophylaxis, the researchers emphasize. Inaddition, 59.3 percent of patients received prophylaxis for more than 24 hoursafter the end of surgery. There is evidence that use of new, broad-spectrumantimicrobials and prolonged use of antimicrobials can promoteantimicrobial-resistant bacteria and increase the incidence ofantibiotic-associated complications, according to Bratzlers study.
A longer duration of antibiotic administration promotesantibioticresistant 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 oneof the drugs commonly used to treat them. Someone who is infected with resistantbacteria is more likely to have a longer hospital stay and require treatmentwith a second- or third-choice drug. These drugs tend to be less effective, moretoxic, and more expensive. By stopping antibiotics within 24 hours after surgeryis complete, we can decrease the development of antibiotic resistance. In termsof SSIs, by taking the steps we have outlined in this study, of ensuringappropriate antibiotic selection, timing and duration, we estimate we canprevent 40 percent to 60 percent of SSIs. However, it is our goal to preventthem all. The CDC is concerned about the problem of antibiotic resistance andthe role it plays in SSIs and HAIs, and this is one of the many projects we areworking on to addressing these problems. Substantial opportunities remain to improve the use ofprophylactic antimicrobials for patients undergoing major surgery, Bratzleradds.
Achieving high rates of performance for appropriateantimicrobial prophylaxis to prevent SSIs will require the development ofsystems in which the knowledge from years of research and recommendation fromclinical practice guidelines are routinely incorporated into practice.
Bratzler adds that his studys findings represent the firststep in a number of measures designed to improve surgical care by encouragingQIOs to work closely with hospitals across the country. I think this projecthighlights how national organizations can work together through local qualityinitiatives to improve quality of care. Many hospitals are voluntarilycollecting this information and have started reporting their own data onantibiotic use to Medicare. Right now, more than 900 hospitals nationwide aresubmitting data and their quality of care for these performance measures toprevent SSIs. The ultimate outcome we would like to see from this project is areduction in the number of SSIs.
Participating in a statewide SIP collaborative, Californiahospitals measurably decreased surgical infections by improving rates ofappropriate antibiotic administration to surgical patients. Overall, teams from26 participating hospitals decreased SSI rates by an average of 10.7 percentacross three measures in just over a year through their voluntary participationin the collaborative, led by Lumetra, Californias Medicare QIO. Between April2003 and April 2004, the participating hospitals teamed with Lumetrasexperts, sharing data and expertise, to decrease surgical infections throughcollaborative learning processes and implementing better methods of care.
The collaborative focused on three infection-preventionquality measures: prophylactic antibiotic selection for surgical patients; prophylactic antibiotics received within one hour prior tosurgical incision; and prophylactic antibiotics stopped within 24 hours of thesurgerys completion. The teams made notable progress, including:
Teams from16 hospitals in Colorado participated with theColorado Foundation for Medical Care (CFMC) in the Surgical Infection PreventionCollaborative. Between March 2003 and March 2004, participating hospital teamsimplemented, tested and tracked changes in prophylactic antibioticadministration. Their progress included:
Several facilities in Texas also saw significant resultsfrom participation in local collaboratives. Working with the Texas MedicalFoundation (TMF), Medicares QIO for Texas, Methodist Dallas Medical CenterNeurosurgery and Orthopedic Surgery departments were able to dramatically boostperformance on five of six SIP quality indicatorsand to achieve 95 percent compliance in five out of six SIPindicators.
Baseline rates and rates at re-measurement included:
At the start of the project, the hospital shared SSI rates with eachsurgical department, identified barriers, and addressed issues with evidencefrom the literature and through discussion. After the nine-month effort, notonly were the measures improved, but there was increased awareness of measureswith the anesthesia group, surgery, and staff.
The Physicians Centre, a 16-bed hospital in Bryan, Texas, hasbeen participating in TMFs SIP collaborative since August 2003, and isworking to improve care for patients having total joint replacements orhysterectomies. An orthopedic surgeon and a gynecologist serve as clinicalchampions and work with a multi-disciplinary team to improve care processes. Theteam used rapid plan-do-study-act (PDSA) cycles to develop and implement a newpre-printed order set that addressed all of the performance measures. PDSAcycles were also used to standardize IV antibiotic administration as the patiententers the operating room. To maintain perioperative patient normothermia,protocols for using patient warming devices are currently being tested.
They had the following results:
The hospitals SIP teamhas overcome barriers such as difficulty in finding a time to meet withsurgeons, documentation problems, and one surgeons reluctance to discontinueantibiotics within 24 hour of surgery. Team leader Chris Allen, RN, CIC, reportsthat, The surgeons are enthusiastic about the project and the team ismotivated and works well together. The team will be monitoring theirperformance measures monthly to ensure their gains are maintained.
Memorial Hermann The Woodlands (MHTW) Hospital also isparticipating in TMFs SIP collaborative. They began piloting improvementmethods with one orthopedic surgeon on his hip and knee arthroplasty cases. Thegoal of their project was to improve the selection and timing of prophylacticantibiotics, then involve other orthopedic surgeons. To accomplish their goal,communication about the project to physicians and hospital staff was essential;these methods implemented include:
Regarding the latter method, MHTWs project was covered byNews-24 in Houston. According to employee Diane Maxwell, The TV news coveragemade people recognize that this was a real, tangible process for improvedpatient outcomes. As MHTW plans to spread improvement to additionalspecialties, they are recruiting additional physician champions and areconducting in-services to hospital staff who will become involved in theproject. For arthroplasties, MHTW has reached 100 percent compliance onappropriate selection of an antibiotic and on administering the antibioticwithin one hour prior to surgery. Discontinuation of antibiotics within 24 hoursafter surgery continues to be a challenge, and the physician champion is talkingto 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 gaugeimprovement: the number of patients who received appropriate prophylacticantibiotics; the number of patients who received prophylactic antibiotics withinone hour of surgical incision; and the number of patients in whom prophylacticantibiotics were discontinued within 24 hours of surgery end time. In NewJersey, rates for all of the surgical infection measures improved from thebaseline period of the project (April 2001 to September 2001) to the firstquarter of 2004.
The rates for the second and third measures increased to 70.33percent 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 4.95percent relative improvement.
PRONJ has supported the sharing of information among NewJersey hospitals to decrease SSIs. For example, one hospital created a form thatassisted its surgeons and other members of the perioperative team in complyingwith recognized standards for prophylactic antibiotic selection, administrationand timing. There was an 80.3 percent relative improvement in the averagesurgical infection prevention rate for the hospital from baseline to the firstquarter of 2004. This tool was shared with other hospitals in a PRONJ-sponsoredlearning session.
Process measures to prevent post-operative infections in NewMexico have significantly improved as a result of the work of participatinghospitals in the New Mexico Surgical Infection Prevention (SIP) Collaborative.Convening this quality improvement project from January through November 2003was the New Mexico Medical Review Association, (NMMRA), under contract with CMS.Out of the eligible 42 New Mexico hospitals, 19 participated in thecollaborative.
Focusing on process measure areas identified as highlyeffective in preventing SSIs, participating collaborative hospitals were ableto, from 2002 to 2003:
For the other effective preventative process measure of selectingappropriate antibiotic measures according to guidelines, rates were alreadyhigh; collaborative participants achieved minimal improvement over the sametime. Hospitals not participating in the collaborative actually decreased theirrate of administering antibiotics within one hour of surgery from 61.9 percentto 50.8 percent, and achieved a minimal rate increase from 23.5 percent to 25.6percent in the postsurgery discontinuation of antibiotics. Based on the nationalproject baseline rates established by CMS in 2001, the work of the New MexicoSIP Collaborative participants was pivotal in the dramatic improvement ofstatewide rates of timely prophylactic antibiotic distribution:
Again, state rates were already high for the other effectiveinfection prevention process measure of selecting appropriate antibioticmeasures according to guidelines, and minimal improvement was achieved. NewMexico SIP Collaborative participating hospitals attended three full-daylearning sessions and an outcomes congress to learn best practices and shareimprovement methods in surgical infection prevention, which included:
New England Baptist (NEB) Hospital in Boston,specializing in orthopedic surgery, started working in earnest with MassPRO in2004, attending seven conferences for heart failure, pneumonia, surgicalinfection prevention (SIP) and quality improvement liaison meetings. As of thethird quarter of 2004, NEB exceeded achievable benchmarks for SIP for all threemeasures. For antibiotics given within one hour before incision, NEB achieved 95percent; for use of appropriate antibiotic, NEB achieved 98 percent; fordiscontinuing antibiotics within 24 hours, NEB achieved 87 percent.
Another Massachusetts hospital that is up-and-coming forbreakthrough performance in SIP is Morton Hospital in Taunton. Morton startedworking with MassPRO in 2004, attending four SIP, pneumonia and heart failurecollaborative meetings and Webex events. The MassPRO HCQIP Hospital Teampresented at Mortons surgical grand rounds in November 2004, and since thattime, Morton has worked closely with the team and reports that they haveachieved 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 itssurgical patients by 59 percent. Using what it learned as a participant in theSIP collaborative, BMC performed multiple small tests of change to overhaul itsperioperative system, including the presentation of baseline data andevidence-based resources to surgical staff, the implementation of standardizedadministration and documentation processes, and the revision of order sets.
Using this model, BMC has also made improvements in other SIPindicators, including appropriate antibiotic selection and the discontinuationof antibiotic therapy within 24 hours. I know I can speak for BaystateMedical Center when I say that the changes which have taken place in ouroperating rooms before and after surgery have been a reflection of the impactMassPRO has had on improving patient care surrounding surgical infectionprevention, says Richard M. Engelman, MD, chief of cardiac surgicalresearch at Baystate Medical Center.
Bratzler D. Use of antimicrobial prophylaxis for majorsurgery, baseline results from the National Surgical Infection PreventionProject. Arch Surg. 2005;140:174-182.