Surgical Infection Prevention: Success Stories NEW MEXICO Collaborative Work of 19 New Mexico Hospitals Significantly Improves Process Measures to Prevent Surgical Infections Process measures to prevent postoperative 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 the Centers for Medicare and Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services, to decrease morbidity and mortality associated with postoperative infection in the Medicare patient population. Out of the eligible 42 New Mexico hospitals, 19 participated in the New Mexico SIP Collaborative. Focusing on process measure areas identified as highly effective in preventing surgical infections, participating SIP Collaborative hospitals were able to, from 2002-2003: Increase their rate of administering p rophylactic antibiotics within 1 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; SIP Collaborative participants achieved minimal improvement over the same time. Hospitals not participating in the SIP 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 post-surgery 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 For more information on the New Mexico SIP Collaborative, contact Carlene Brown, MPH, CPHQ, NMMRA hospital quality improvement manager, at (505) 998-9733 or cbrown@nmqio.sdps.org. This material was prepared by the New Mexico Medical Review Association, the Medicare Quality Improvement Organization for New Mexico, 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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