Surgical site infection prevention through prophylactic antibiotic protocols

Infection Control - Surgical Infection Prevention Project

Post-operative infection is a major cause of injury to patients. According to the Centers for Medicare and Medicaid Service (CMS) and the Centers for Disease Control and Prevention (CDC) surgical site infection occurs in about 2-5% of clean extra-abdominal surgeries and in approximately 20% of intra-abdominal surgeries. It is a major cause of patient injury, mortality and health care cost. The CDC and CMS work together to develop a national healthcare quality improvement project to prevention post-operative infection. It will be the purpose of this project to investigate the causes surrounding post-operative infection and improve associated rates of morbidity and mortality while also helping to improve the selection of effective prophylactic antibiotics.

Introduction

Each surgical site infection is believed to increase the patient's hospital stay by an average of seven days and can add over to $3,000 in charges (Martone, Culver & Haley, 1992, p. 577-96). These patients are also five times as likely to require readmission to the hospital and have twice the incidence of peri-operative mortality as those patients who do not experience surgical site infection. Even with advances in infection control procedures, these infections continue to be a substantial cause of morbidity and mortality in hospitalized patients. These patients are 60% more likely to spend time in the intensive care unit (ICU). Several studies have indicated that the preoperative administration of antibiotics selected carefully and empirically for likely pathogens can be effective in the reduction of infection incidents. It has also been noted that the use of systemic processes and guidelines surrounding the appropriate use of peri-operative antibiotics also have a significant effect on the rate of surgical site infection (Mangram, Horan, Pearson, et.al. 1999). There are currently three primary project indicators which are to be applied to specific surgical procedures: 1) Antibiotics administered within one hour before surgical incision; 2) Administration of antibiotics consistent with current recommendations; and 3) Discontinuation of prophylactic antibiotics within twenty-four hours after surgery. It is my plan to develop a Surgical Infection Prevention Collaborative Data Collection Tool that will be used for the method of surveillance, analysis and intervention and based upon the PLAN-DO-CHECK-ACT of quality improvement. Secondly, I will form a committee that will be responsible for overseeing the various programs for surveillance, prevention and control of infection and serves as the central review and policy making body for the Infection Prevention and Control program. The committee is multidisciplinary including members of the medical staff, nursing, administration, pharmacy and laboratory.

Third, I will work with the tem to recommend policies and procedures to protect the patient and healthcare worker and to ensure the optimal operation of the healthcare system.

Fourth, I will identify with the team the area of concern, and then a corrective action plan will be formulated with the authority and responsibility to act on the findings.

History

Provena Health is a community-based healthcare organization which strives to provide high quality health care services in a safe and cost effective manner. The Infection Prevention and Control Plan support this effort by defining a systematic, coordinated and continuous approach to improving performance by focusing upon surveillance, prevention and control of infections throughout the hospital. Infection prevention and control services are provided through the collaborative efforts of the Infection Control Program and Employee Health Services

There are three principle goals for the Provena Health Infection Prevention and Control Plan:

Protect the patient by 1) reducing nosocomial infection rates in an effort to reduce morbidity and mortality and 2) shorten periods of illness and hospitalization

Protect healthcare workers, visitors and others in the healthcare environment. This will be accomplished using methods such as isolation, barrier precautions, case investigation, education, immunization, and employee health programs that protect employees from job-related exposures.

Accomplish the previous two goals in a cost effective manner by 1) preventing costs to the healthcare payer associated with the treatment of complications due to nosocomial infections and 2) avoiding costs to the organization resulting from infection related absenteeism and liability.

Organizational Background Analysis of Current Situation/Process

The Infection Prevention and Control Plan is a multi-disciplinary collaborative plan designed to control the spread of infection based upon the clinical needs and demographics of our patients and employees. The CDC National Nosocomial Infections Surveillance (NNIS) system is sued to define infections. The plan is under the direction of the infection disease physician contracted by Provena Health to provide oversight for the Infection Control Program. The plan is designed to protect the patient and healthcare worker and to ensure the optimal operation of the healthcare system by means of the following:

Managing critical data and information, including surveillance of nosocomial infections.

Setting and recommending policies and procedures.

Intervening directly to interrupt the transmission of infectious diseases.

Educating and training healthcare workers, providers, patients and the community.

While infection control if the responsibilities of all Provena Health employees, the following are key personnel resources with specific responsibilities for Infection Prevention and Control Plan implementation.

Antibiotic and Infection Control Committee (AICC) This committee is responsible for overseeing the various programs for the surveillance, prevention and control of infection and serves as the central review and policy-making body for the Infection Prevention and Control program. The committee is multidisciplinary including members of the medical staff, nursing, pharmacy, administration, laboratory, employee health and occupational medicine.

Infectious Disease Physician - This physician has expertise in infection control and knowledge of performance improvement methodologies. he/she chairs Provena Health's AICC. The infectious disease physician has the responsibility and authority to ensure compliance with Infection Control Policies and procedures, to make decisions regarding their implementation and institute any specific surveillance, isolation, prevention or control measures deemed necessary when there is reason to believe any patient, healthcare worker or other person may be in danger of contracting or transmitting an infectious disease or epidemiologically significant microorganism.

Infection Control Practitioner (ICP) - registered Nurse or medical technologist (ASCP) with special training in infection control. These practitioners perform surveillance, analyze data, and implement policies and procedures to prevent and/or disrupt the transmission of disease, educate staff on infection control practices and act as a resource to Provena Health employees.

Employee Health Service (EHS) Employee Health Services develop and implement systems of diagnosis, treatment and prevention of infectious disease in healthcare workers by providing screening, immunizations, education on work related illnesses and exposures, and implementing policies and procedures to prevent/control the outbreak of infection among personnel. These activities include, but are not limited to, Tuberculosis screening, exposure monitoring including blood borne pathogens, work restriction management and maintaining employee records. Relevant data from these activities are presented to the AICC.

Laboratory Services General medical laboratory (GML) reports positive microbiology findings to patient care providers and to the Infection Control Practitioner. Data is also provided to the AICC on the prevalence of specific pathogens.

Clinical Nurse Specialists and Nurse Managers Assist with surveillance data collection, analysis, and interpretation. Participate in specific improvement processes based upon findings.

Pharmacy a pharmacist with specialty training in infectious disease acts as a resource to patient care providers and is the AICCs link to the Pharmacy and Therapeutics committee. Assists with data collection, analysis and interpretation. Participates in specific improvement activities based on the findings.

Patient Care Providers Physicians and clinical staff work to prevent and control infections through patient assessment, education and treatment, implementation of policies and procedures relating to infection control and the use of protective equipment and supplies. Patient care providers are responsible to report infections to the Infection Control Practitioner when identified.

Support Services supporting patient care such as Environment of Care committee, Facilities Management, Safety Committee, and Materials Management are all integral to the Infection Prevention and Control plan by implementing policies and procedures that ensure a clean environment and supplies.

Quality Resources Provides supports for data collection, analysis and trending as well as support for quality improvement efforts identified by the AICC.

Current Status and Analysis

Date Period

Q3-2004

Measure Title

Data Period

Rate/Value

Numerator

Denominator

Missing

Excluded

Cat-E) Invalid Cases Population Numerator Data SIP-1a Prophylactic

Jul-04

Antibiotic received within Aug-04 one hour prior to surgical incision-

1-Sep overall rate

SIP 1a Subtotal

SIP 1b Jul-04-75% 3-4 0-0-30 Prophylactic antibiotic Aug-04-80% 4-5 0-0-26 received within one hour prior to Sep-04 surgical incision-

CABG SIP-1b Subtotal

SIP-1c Jul-04 0-0 0-0-0-34 Prophylactic Antibiotic received within Aug-04 one hour prior to surgical incision-

Sep-04 cardiac surgery

SIP -1c Subtotal

Measure Title

Data Period

Rate/Value

Numerator

Denominator

Missing

Excluded

Cat-E) Invalid Cases

Population

Numerator

SIP 1d Data Prophylactic

Jul-04 antibiotic received within Aug-04 one hour prior to Sep-04-50% 4-8 0-0-35 surgical incision- hip arthroplasty

SIP 1d Subtotal

SIP 1e Prophylactic

Jul-04 antibiotic received within Aug-04 one hour prior to surgical incision

Knee arthroplasty

SIP 1e Subtotal

SIP 1f Prophylactic

Jul-04 antibiotic received within Aug-04 one hour prior to surgical incision

Colon Surgery

SIP 1f Subtotal

Measure Title

Data Period

Rate/Value

Numerator

Denominator

Missing

Excluded

Cat-E) Invalid Cases SIP 1-g

Population

Numerator

Prophylactic

Data antibiotic Jul-04-42.90% 3-7 0-0-27 received within one hour Aug-04-30% 3-10 0-0-21 prior to surgical incision-

Sep-04 hysterectomy

SIP 1g Subtotal

SIP 1h Jul-04-100% 1-1 0-0-34 Prophylactic antibiotic Aug-04 0% 0-1 0-0-30 received within one hour Sep-04 0% 0-1 0-0-42 prior to surgical incision-

Vascular surgery

SIP 1h Subtotal

SIP 2a Jul-04-100% 30-30 0-0-4 Prophylactic

Antibiotic selection

Aug-04 for surgical patients Sep-04-94.70% 36-38 0-0-5 Overall Rate

SIP 2a Subtotal

Measure Title

Data Period

Rate/Value

Numerator

Denominator

Missing

Excluded

Cat-E) Invalid Cases

Population

Numerator

SIP 2b Data Prophylactic

Jul-04

Antibiotic selection for Aug-04 surgical patients

CABG Sep-04-100% 10-10 0-0-33 SIP 2b Subtotal

SIP 2c Prophylactic

Jul-04

Antibiotic selection for Aug-04

Cardiac Surgery

Sep-04 0-1 0-0-42 SIP 2c Subtotal

SIP 2d Prophylactic

Jul-04

Antibiotic selection for Aug-04 hip arthroplasty

Sep-04-100% 8-8 0-0-35 SIP 2d Subtotal

Measure Title

Data Period

Rate/Value

Numerator

Denominator

Missing

Excluded

Cat-E) Invalid Cases SIP 2e

Population

Numerator

Data Data Prophylactic

Jul-04

Antibiotic selection for Aug-04 surgical patients

Knee arthroplasty

SIP 2e Subtotals

SIP 2f Prophylactic

Jul-04

Antibiotic selection for Aug-04 surgical patients

Colon Surgery

SIP 2f Subtotals

SIP 2h Prophylactic

Jul-04

Antibiotic selection for Aug-04 surgical patients

Vascular surgery

SIP 2h Subtotals

Measure Title

Data Period

Rate/Value

Numerator

Denominator

Missing

Excluded

Cat-E) Invalid Cases Population Numerator Data SIP 3a Prophylactic

Jul-04 antibiotics d/c'd within 24 hours after Aug-04 surgery end time

Overall Rate

SIP 3a Subtotal

SIP 3b Prophylactic

Jul-04 antibiotics d/c'd within 24 hours after Aug-04 surgery end time

CABG Sep-04-70% 7-10 0-0-33 SIP 3b Subtotal

SIP 3c Prophylactic

Jul-04 antibiotics d/c'd within 24 hours after Aug-04 surgery end time

Cardiac Surgery

SIP 3c Subtotal

Measure Title

Data Period

Rate/Value

Numerator

Denominator

Missing

Excluded

Cat-E) Invalid Cases

Population

Numerator

SIP 3d Data Prophylactic

Jul-04 antibiotics d/c'd within 24 hours after Aug-04 surgery end time

Hip arthroplasty

SIP 3d Subtotal

SIP 3e Prophylactic

Jul-04 antibiotics d/c'd within 24 hours after Aug-04 surgery end time knee arthroplasty

SIP 3e Subtotal

SIP 3f Prophylactic

Jul-04 antibiotics d/c'd within 24 hours after Aug-04 surgery end time

Colon surgery

SIP 3f Subtotal

Measure Title

Data Period

Rate/Value

Numerator

Denominator

Missing

Excluded

Cat-E) Invalid Cases

Population

Numerator

Data Data SIP 3g Prophylactic

Jul-04 antibiotics d/c'd within 24 hours after Aug-04 surgery end time hysterectomy

SIP 3g Subtotal

SIP 3h Prophylactic

Jul-04 antibiotics d/c'd within 24 hours after Aug-04 surgery end time

Vascular surgery

SIP 3h Subtotal

Date Period Quarter 4-2004

SIP-1a Prophylactic

Oct-04

Antibiotic received within Nov-04 one hour prior to surgical incision-

Dec-04 overall rate

SIP 1a Subtotal

SIP 1b Oct-04 0-0 0-0-37 Prophylactic antibiotic Nov-04-50% 5-10 0-0-36 received within one hour prior to Dec-04 surgical incision-

CABG SIP-1b Subtotal

SIP-1c Oct-04-100% 1-1 0-0-36 Prophylactic Antibiotic received within Nov-04 one hour prior to surgical incision-

Dec-04 cardiac surgery

SIP -1c Subtotal

Measure Title

Data Period

Rate/Value

Numerator

Denominator

Missing

Excluded

Cat-E) Invalid Cases

Population

Numerator

Data Data Prophylactic

Oct-04 antibiotic received within Nov-04 one hour prior to Dec-04-50% 2-4 0-0-31 surgical incision- hip arthroplasty

SIP 1d Subtotal

SIP 1e Prophylactic

Oct-04 antibiotic received within Nov-04 one hour prior to surgical incision

Dec-04

Knee arthroplasty

SIP 1e Subtotal

SIP 1f Prophylactic

Oct-04 antibiotic received within Nov-04 one hour prior to surgical incision

Dec-04

Colon Surgery

SIP 1f Subtotal

Measure Title

Data Period

Rate/Value

Numerator

Denominator

Missing

Excluded

Cat-E) Invalid Cases SIP 1-g

Population

Numerator

Prophylactic

Data antibiotic Oct-04-83.30% 5-6 0-0-31 received within one hour Nov-04-56% 5-9 0-0-37 prior to surgical incision-

Dec-04 hysterectomy

Discussion

The general inclusion data for this information was obtained via evidence of a selected ICD-9 procedure code during the hospital admission. General exclusion criteria included patients who were on antibiotics at the time of admission, except for those patients undergoing colon surgery who were on oral antibiotics. Also excluded were patients who were being treated for an infection prior to the first surgical procedure of interest, patients who had antibiotic start dates missing. The numerator data includes all patients who receive antibiotics within one hour before surgical incision (within two hours if vancomycin is required for prophylaxis). The denominator consisted of patients meeting the general inclusion criteria and measure specific exclusions (patients undergoing colon surgery who were given prophylactic oral antibiotics only, and those on whom it was unable to be determined if an antibiotic was started within one hour of the surgery start time due to missing time values.

Arguments for change

Studies clearly indicate that antimicrobial prophylaxis is the most effective when provided prior to the initial incision. Risk of infection is actually felt to increase when prophylaxis is given either too early (meaning more than 2 hours prior to initial incision) or too late (after initial incision) (Classen, Evans, et.al. 1992). The most optimal time for administration would appear to be in the 30 to 60 minutes prior to the initial incision. A brief course of antimicrobial prophylaxis shortly after procedures is no longer considered to be effective (Mauerhan et.al. 1994; Harbarth, Samore, Lichtenberg & Carmelly, 2000; Wymenga, Hekster, Theeuwes et.al., 1991). In the data obtained from Provena, there appeared to be a large amount of variance between the type of surgeries being performed which received prophylaxis within the specified time, or at all. In addition, the number of patients who were excluded from the data was also high, although no notation is made as to the reason for exclusion, whether it is due to pre-existing antibiotic prescription or lack of documentation surrounding the time of antibiotic administration. It is apparent that the mechanism is in place for the changes to be made. There appears to be a lack of process regarding the predictability and consistency of the administration and documentation of issues surrounding the rate of administration of prophylaxis, which would be a point of change well addressed by my project.

Proposed Strategic Plan to form a committee that will be responsible for overseeing the various programs for surveillance, prevention and control of infection and serves as the central review and policy making body for the Infection Prevention and Control program. The committee will continue to be multidisciplinary in form and include the members of the medical staff, nursing, administration, pharmacy and laboratory staff. I also plan to work with this team to recommend policies and procedures meant to protect not only the patient but healthcare workers as well to ensure optimal operation of our healthcare system within recommended infection control guidelines, proven in random controlled trials. I plan to identify with the team areas of concern, such as have been demonstrated by the statistical data contained in this paper. We will form corrective action plans as well as obtain the authority and responsibility to act on these plans. These action plans will be appropriate to the cause scope and/or severity of the problem identified and will include (but not be limited to); 1) implementation of surveillance, prevention and control measures to include outbreak management and investigation; 2) developing and reviewing policies and procedures related to infection control and employee health and; 3) using the Quality Improvement process to (re) design and define processes to improve infection prevention and control practices. It will also fall within the scope of this committee to educate medical staff, employees and patients on infection prevention and control. We will annually evaluate our Infection Control and Prevention plan, policies, data and information from the previous year, in the first quarter of each year.

Expected Outcomes/Future Assessment

It is my belief that the interventions I propose will allow our health system to improve quality of care as well as reducing the rates of nosocomial infections, especially those related to surgical intervention. Data will be analyzed and compared to the NNIS computer program, results being benchmarked against this program. Areas of concern will be identified, and with the implementation of a standardized method of surveillance and periodic re-evaluation it will be possible to meet or exceed those benchmarks set nationwide.

Conclusion

There is no doubt that increased surveillance and set procedures can eventually reduce the risk of nosocomial and surgical site infection. It has been proven in the literature and the benchmarks stand. I believe the information from this project will improve the outcomes for our surgical patients, reduce morbidity and mortality while keeping hospital bed days down and reducing the financial burden on both the individual and the organization.