Surgical Infection Prevention: Success Stories MARYLAND Maryland Surgical Infection Prevention Collaborative Successful in All Three Required Measures The Maryland Surgical Infection Prevention (SIP) Collaborative held their outcomes congress on March 31, 2004. The session featured the success stories and struggles of 13 hospitals, which presented their improvement methods and results. One of the guest speakers, Dr. Dale Bratzler highlighted evidence and results from the National SIP project and the upcoming Surgical Care Improvement Project that will expand the SIP project to additional areas. Eighteen hospitals began the project in February 2003 with 16 of those completing it. The project’s results are listed below: Required measures Baseline Final % Change Timely antibiotic administration 72.0% 91.9% 19.9 % Use of recommended antibiotics 77.3% 90.4% 13.1% Discontinue antibiotics within 24 hours 49.3% 81.9% 32.6% North Arundel Hospital Joined Maryland Initiative to Build on Success Achieved in National SIP Collaborative Working with Delmarva Foundation, Medicare’s Quality Improvement Organization for Maryland, North Arundel Hospital has continued to make strides in their prevention of surgical infections. The hospital was able to triple the number of cases between surgical site infections and showed a downward trend in overall infection rate of 2.7 percent in 1 st quarter 2002 to 0.8 percent in 4 th quarter 2003. They also showed improvement in 2 of the 3 required measures as well as improvement in hospital chosen optional measures in shaving avoidance and normothernia. Baseline rates and rates at re-measurement (for period beginning 1/03 and ending 1/04): On time antibiotics: from 78.1 percent to 89.4 percent Appropriate prophylactic antibiotics: from 84.4 percent to 91.5 percent Discontinuation of antibiotics: from 85.4 percent to 83.0 percent Normothermia (keeping patient body temperature at normal levels): from 70.5 percent to 97.2 percent Shaving avoidance: from 100 percent to 100 percent (began at 73.7 percent in July of 2002) North Arundel Hospital was part of the National SIP initiative in 2002. The baseline rates shown above are their rates at the beginning of the Maryland SIP collaborative in January 2003. North Arundel pulled together a strong team which included a clinical champion, who was also the Chair of the Maryland SIP collaborative, key representatives from anesthesiology, OR, Outcomes Management and Infection Control. Hospital leadership was very supportive of the initiative. The SIP team provided staff education and stabilization of their antibiotic process through the use of protocols and guidelines. North Arundel increased staff awareness of the measures through participation in the SIP collaborative and through their internal collaborative practice teams. Holy Cross Achieves Dramatic Improvement in Antibiotic Timing As a participant in the Maryland SIP Collaborative, Holy Cross Hospital began piloting their improvement efforts with selected surgeons in their total hip replacement and laminectomy surgeries. They soon expanded their efforts to include all patients undergoing these procedures. Their efforts included a standardized antibiotic administration process through the use of standing orders, systematic documentation of antibiotic administration, and surgical staff feedback on both compliance and infection rate data. The anesthesia department at Holy Cross accepted responsibility for starting the antibiotic timely. Literature and education were provided on the benefits to discontinuing the antibiotic within 24 hours. Their results were variable, but overall they showed good improvement as shown below. Performance Measure Baseline January 2004 Antibiotics administered within one hour prior to surgery 38% 90% Use of recommended antibiotics 73% 97% Antibiotics discontinued within 24 hour of surgery 75% 97% The hospital’s SIP team educated staff and increased awareness of the measures by providing literature and updated data using posters throughout the hospital and by presenting at meetings. They also chose to work on an optional measure of shaving avoidance and in improving this measure removed all razors from the OR, established a protocol to determine when shaving was appropriate and posted a “no shave zone” poster in the OR. Circulating nurses wear “no shave zone” buttons. The work of the SIP team is being adapted for other surgery populations. PeninsulaRegionalMedicalCenter Reduces Surgical Infection Rates by 33%   Peninsula Regional Medical Center (PRMC) participated in the Maryland SIP Collaborative by targeting their improvement efforts on their CABG and valve replacement surgery patients. Their methods included creation of a pre-op order set with current antibiotic recommendations, education of OR and anesthesia staff, designation of responsibility for preoperative antibiotic administration to the anesthesia department and standardizing their administration process. The team approached the surgical infection prevention strategies as a safety culture issue. The changes they made related to this included: Placing performance improvement boards in strategic locations Providing literature and education through one-on-one sessions as well as through audio and video tapes Posters in the OR Informational materials in the doctor’s lounge An educational bulletin board in the OR which was updated periodically PRMC reports that their data showed a decrease in infection rate of 33 percent in 2003. Results of their efforts on the required measures are documented below: Performance Measure Baseline December 2003 Antibiotics administered within one hour prior to surgery 36% 87% Use of recommended antibiotics 92% 97% Antibiotics discontinued within 24 hour of surgery 0% 28% While the discontinuance of antibiotics continues to be an area where PRMC struggles, they have made improvements. Some of the methods they have implemented to overcome this include providing literature to the cardiovascular surgeons, education of the nurse practitioners and physician assistants of the benefits of discontinuing the antibiotic within 24 hours and revising current education material to include statements about the benefits and expectations of timely antibiotic discontinuance. For more information, contact Nicki Shugart, Communications Manager at Delmarva Foundation for Medical Care, Inc., nshugart@dfmc.org or 410-763-6224. This material was prepared Delmarva Foundation for Medical Care, Inc. , the Medicare Quality Improvement Organization for Maryland , under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents do not necessarily reflect CMS policy.

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