Surgical Infection Prevention: Success Stories NEW YORK IPRO, Medicare’s Quality Improvement Organization for New York conducted a statewide voluntary Surgical Infection Prevention Collaborative with 22 hospitals; below is a description of one hospital’s success: Glen Cove Hospital Achieves Dramatic Improvement on SIP Measures Glen Cove Hospital, part of the 15-hospital North Shore-Long Island Jewish Health System, enthusiastically participated in IPRO’s voluntary Surgical Infection Prevention (SIP) Collaborative, which ran from July 2003 through March 2004. The objective of this collaborative was to reduce surgical infections by improving the selection and timing of prophylactic antibiotics. Glen Cove started out with an excellent rate of appropriate selection of antibiotics, so they focused mostly on the timing issues. They targeted their efforts initially on their primary hip and knee arthroplasty patients, intending to spread improvements throughout their institution once established in this population. Team members came together from many different departments, including surgery, pharmacy, infection control, and quality management. Of great importance was the active involvement of the leadership in several departments, including Dr. David Berger, Chairman of Anesthesia, Dr. Eugene Krauss, Chairman of Orthopedics, the Director of Perioperative Services, the Director and Assistant Director of Pharmacy, and the Manager of their Total Joint Program. The team used a series of Plan, Do, Study, Act (PDSA) cycles to plan out their strategy. Thanks to the involvement of senior administration and clinical directors, improvements came rapidly. A previous policy, which stipulated that pre-operative antibiotic was to be given in the holding area, was changed so it could now be given in the OR. The pharmacy researched the availability of ready-mix Cefazolin to facilitate its administration and the anesthesia department accepted the primary role for antibiotic pre-operative administration. An almost immediate improvement in the timing of the first dose of antibiotic was measured, with the performance improving from a baseline rate of 46% in July 2003, to over 90% by September 2003, and reaching 100% by January 2004 where it stayed until the end of the collaborative. The team also focused on the other challenging performance measurement, namely discontinuing antibiotic prophylaxis within 24 hours of the end of surgery. During the fall, meetings were held with the surgeons to discuss the length of postoperative antibiotics and infection control also started to monitor post-op antibiotics. Shortly after, a meeting between the division leaders resulted in the development of a new protocol for timely discontinuance of prophylactic antibiotics that was presented to both QA and P&T Committees. Finally, the changes were finalized and written into the pre-op sheet, pre-printed orders, care maps, and the OR tracking tool. Very rapid improvements were noted in the performance measure, which rose from under 50% in the fall of 2003 to 100% by the beginning of 2004. The team is strongly dedicated to building on the progressive momentum that they have started through this collaboration; by the middle of 2004 they had already begun to examine and track colon surgeries for these same performance measures. The Collaborative was led by IPRO, the Medicare Quality Improvement Organization for New York, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. IPRO is continuing to work with hospitals statewide to improve quality of care and to continue to decrease their rates of surgical infection. For more information about IPRO’s quality improvement resources for surgical infection prevention, contact Dr. Charles Stimler, (516) 326-7767, ext. 634, email Cstimler@nyqio.sdps.org or Sheila McCullagh, Director, Consumer Protection & Outreach, (516) 326-7767 ext 619 or Smccullagh@nyqio.sdps.org This material was prepared by IPRO, the Medicare Quality Improvement Organization for NewYork, 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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