Surgeons Talking Found Unhealthy (STFU)

There’s an interesting (but very small) pilot study in the British Journal of Surgery that examines the relationship between operating room noise and surgical site infection (SSI) rates. A Swiss group--which previously correlated a subjective perception of increased noise with SSI--measured sound levels in 35 ORs during elective abdominal operations. Median sound levels were significantly higher during cases of patients who subsequently developed SSI (43.5 dB vs. 25.0 dB, p=0.04). Also of note: talking about non-surgery-related topics was associated with higher sound levels, and sound levels increased about 60 minutes after incision. Since we already know that SSI risk increases with the duration of a procedure, it may be that longer surgeries are also associated with more, and louder, non-surgical conversations as the team becomes bored or distracted (though not statistically significant, the procedure duration was longer for SSI patients in this study (mean of 390 vs. 255 minutes)). And as the authors note, higher sound levels could simply reflect the difficulty of a procedure (suction machines, alarms, louder and longer conversations, primal screams, etc.). Future studies could help determine if higher OR sound levels are just markers for difficult, stressful cases, or if more noise negatively affects surgeon performance (or both!).

Call for Algorithms: MRSA surveillance and pre-op antibiotics in cardiac and orthopedic surgery

I'm involved in an AHRQ-funded contract to identify and then study algorithms for SSI prevention in cardiac and orthopedic surgery. In an effort to expand our search for what methods others are using to prevent resistant Gram-positive SSIs, they asked that I post the call for algorithms here.  Our hope is that IPs or hospital epidemiologists could quickly send us their protocols. This study involves University of Iowa, The Joint Commission, AHRQ, and University of Maryland.  Thanks for your help!

Submit your hospital’s pre-operative algorithms and protocols for antimicrobial prophylaxis for patients with resistant Gram-positive organisms undergoing orthopedic and cardiac procedures

We are seeking examples of algorithms, protocols, pathways, policies and procedures, and standing orders that address selection and administration of antimicrobial prophylaxis for cardiac and orthopedic surgery patients. If your organization routinely screens pre-operative patients for MRSA, it would be helpful to also include screening and de-colonization algorithms and protocols.

The goal of this activity is to develop consensus-based algorithms for widespread dissemination that will contribute to reducing the rate of surgical site infections. This collaborative project, funded by the Agency for Healthcare Research and Quality (AHRQ), is being implemented by the University of Iowa, the University of Maryland, and The Joint Commission, with guidance from an expert panel of surgeons, anesthesiologists, and epidemiologists.

Please submit the information by fax or email to: Michele Bozikis at (630) 792-4922; mbozikis@jointcommission.org

Project Goals and Objectives
The goal of this project, "Optimizing Pre-Operative Antibiotic Prophylaxis for Cardiac and Orthopedic Procedures," is to determine whether a pre-operative antibiotic prophylaxis algorithm that includes the use (including selective use) of antibiotics shown to be effective against resistant gram-positive organisms is effective in reducing the number of surgical site infections (SSIs) attributable to resistant gram-positive organisms.

The objectives include:
1. Identify, through a review of the literature and existing studies, the most promising algorithms for pre-operative antibiotic prophylaxis for the prevention of SSIs in certain cardiac and orthopedic procedures
2. Develop one or more algorithms that incorporate the use (including selective use) of antibiotics shown to be effective against resistant gram-positive organisms
3. Design and conduct a study that compares the new algorithm(s) against standard algorithm(s) used for administering pre-operative antibiotic prophylaxis of SSIs in certain cardiac and orthopedic procedures

Future Opportunities
If additional funding is received, we will begin recruiting hospitals for participation in a study to test the effectiveness of the consensus-based algorithms at reducing SSIs. Recruitment will begin in Fall- 2011. Information will be shared as it becomes available. Stay tuned

For More Information
If you have questions about this project, please call Michele Bozikis at (630) 792-5922 or Joanne Hafner at (630) 792-5970; jhafner@jointcommission.org

A surgical site infection enhancement bundle?

A new paper in the Archives of Surgery evaluated the implementation of a surgical site infection (SSI) prevention bundle for colon surgery (see free text of the paper here). The bundle contained the following components:

• Omission of mechanical bowel preparation
• Preoperative and intraoperative patient warming
• Increased concentration of inspired oxygen during and immediately after the surgical procedure
• Limiting intraoperative intravenous fluid volumes
• Use of wound barriers to protect the surgical wound from contamination during the procedure 

Each component of the bundle was supported by 1 or more randomized trials demonstrating reduction in SSIs. About 200 patients were randomized to receive either the bundle or standard care. SSIs were determined by IPs using CDC case definitions. The study was terminated after a planned interim analysis revealed a <1% chance of showing a positive effect of the bundle were the study to continue to the accrual goal.

The overall rate of infection was 35%. In the control group, 24% of patients developed an SSI vs. 45% in the intervention group (p .003). In multivariate analysis, the bundle was shown to an independent predictor for SSI (RR 2.49, CI95 1.36-4.56).

I was struck by the very high rate of infection in this study, so I looked at CDC's most recent surveillance report, which shows that the mean pooled infection rates for colon surgery depending on risk category ranges from 3.99% to 9.47%. The authors postulate that their case ascertainment may be greater since the study was performed at a VA hospital where outpatient follow-up of patients is much easier to track. However, even in light of that, the rate still seems quite high. But on the other hand, unless there is something very unique about these patients or the care provided at this hospital, you might think that an effective prevention bundle would have even more impact in a setting with exceedingly high infection rates. This raises more concern that the bundle was not just ineffective but actually increased the risk of post-operative infection.

This paper is another example of how immature implementation science remains. I think the authors of this paper are correct to conclude that bundles of evidence-based interventions need to be formally tested before there is wide spread implementation.

1st Annual Illinois Conference on HAI: The SSI rates don't exist anymore edition



I ate all of the Illinois-shaped
chocolates. Sorry!

I had the pleasure of attending and speaking at the Illinois APIC conference this past Friday in Springfield, Illinois.  Lincoln was everywhere for some reason; I was expecting Homer or Bart statues...

The first speaker was Kathy Allen-Bridson, RN BSN CIC who is a Nurse Consultant at CDC's NHSN.  She gave an excellent talk describing how to apply NHSN definitions. She, Marc Wright (one of the conference organizers), Joan Hebden, Gloria Morrell and Teresa Horan have published a series of cases studies that aid IPs in the application of NHSN definitions of HAIs.  The first three of these have appeared in the June, September and October issues of APIC. (scroll down to the Special Article section)  I do think that these should be free to everyone and not require a membership or subscription, especially given the large role that CDC had in creating these vignettes.

As far as CLABSI definitions, there was some interesting discussion around Criterion 2 that requires the "same" skin contaminant from >2 blood cultures drawn <2 days apart. For the definition of same, NHSN suggests

that organisms are the same if they have the same antimicrobial sensitivities or only differ in susceptibility to ONE antibiotic.  Thus if they differ by 2 or more antibiotic susceptibilities then they are different and the BSI is not a CLABSI.  The interesting discussion came up around what to do with susceptibilities tested by the microbiology lab, but not reported.  Since some/many labs only report susceptibilities to clinicians for antibiotics on formulary or unrestricted antibiotics, should IPs go to the lab and search for susceptibility mismatch on antibiotics tested in the lab but not reported?  A show of hands suggested that 50% do the extra search and 50% don't.  This is something NHSN might want to address.

The second speaker was Maggie Dudeck MPH CPH, who is also with CDC's NHSN. She gave a really thorough talk on how to use NHSN for analysis and generate reports.  I found this very useful.  Additionally, she discussed that NHSN will no longer report SSI rates!  As of now, NHSN will only report SSI Standardized Infection Ratios (SIRs). You can read more about SSI SIRs here in the NSHN special edition newsletter.  Basically, SIRs are estimated by dividing reported SSI rates by expected infection rates estimated using a "to be published" logistic regression formula.  Thus, SIR>1 will suggest SSIs greater than expected and SIR<1 will suggest SSIs lower than expected.  This is pretty interesting, although as a patient and clinician, I would still want to see that actual rates. (FYI in CLABSI they will report rates and SIR, which I think is better)  In addition, if new information becomes available that might improve the SIR calculation, it is not clear how quickly that will be incorporated, if at all.

Overall, it was a great conference. I had a lot of fun speaking about "Reducing CLABSIs through Blood, Sweat and Tears, With a Happy Ending", interacting with the 200 or so IPs in attendance and eating all of the Illinois-shaped chocolates.  It was also fun to be recognized by a few people who read this blog. Thanks for saying hello!

Laziest possible post about the new CMS rule

I am on vacation. Last week I biked across Iowa with 9,999 other people (see photo below), and I’m now in Michigan, recovering from my bike ride across Iowa. So I haven’t done much deep thinking about the new CMS rule related to healthcare associated infections. From what I understand, participation in the Medicare program (at least receipt of full payment) will soon require surveillance and reporting (through NHSN) of CLABSI (beginning in 2011; ICU only) and SSI (beginning in 2012). The rates will eventually be reported via the hospital compare website. This doesn’t mean a lot to hospitals that already perform CLABSI and SSI surveillance, unless they don’t currently report through NHSN, in which case they’ll have to get enrolled.

We’ve already blogged about pitfalls in public reporting, and about problems with the NHSN definitions, validation, etc. So I really don’t have anything new to say about this rule. I refer all interested readers to a six-part series at Safe Healthcare (only 2 posts so far, 4 to come) on the new rule.

Rhinoceroses and Total Hip Arthroplasty

Distinctions are very important. I was just visiting Ohio last week and had the chance to visit the Columbus Zoo. It's a pretty cool place if you like zoos. I enjoyed reading about various animals and learned that the Black Rhino is endangered, while the White Rhino is not. Thus, it would make sense to spend your conservation money, if you have some, on Black Rhinos first, since time is running out. In infection control, we ought to do the same thing, but in reverse; spending our limited resources on preventing more common infections first. Also, with the rise of public reporting and other methods of interhospital comparison, efforts must be made to place hospitals on a level playing field. There is a nice study that highlights these two issues in the May ICHE by Surbhi Leekha and colleagues at the Mayo Clinic in Rochester, MN.

They examined at a 5-year cohort (2002-2006) of all total hip arthroplasties (primary and revision) and looked to see who developed SSI, using CDC definitions. After controlling for age, gender and NNIS index, patients who had a revision total hip arthroplasty had twice the odds of SSI compared to primary surgery (OR=2.2, 95% CI 1.3-3.7). The difference was even more stark when outcomes were restricted to deep or organ space SSI with revisional surgery associated with four times the odds of SSI (OR 3.9, 95% CI, 2-7.9). One note, they didn't appear to control for duration of surgery as a confounder, even though it was associated with both revisions and SSI. I think this is correct. They were not completing a risk-factor study, but were interested in outcomes.

The usual caveats apply to these types of studies including a single center study and a relatively unique single center at that. However, this is an important study and if these findings hold up at other institutions, which they most certainly will, this suggests that the case-mix of revision and primary hip arthroplasty must be taken into account when SSI rates are reported and hospitals compared. Perhaps an easier solution, as the authors suggest, is to treat them as two different animals, if you will, and report them separately. Also, if one wanted to target specific infections or high-risk procedures, these results suggest targeting revision surgeries over primary ones.

Note: Surbhi is joining the group at my old Maryland stomping grounds and I know everyone is excited for her to arrive.