Perioperative Enterprise Committee Surgical Site Infection Report. May 15, 2008

Transcription

1 Perioperative Enterprise Committee Surgical Site Infection Report May 5, 8

2 VUH ORs

3 OB Infections, by Quarter Superficial SSI 8 Overall SSI Active Surveillance Q3 5 Q Q 7 Q 7 Q3 7 Q 7 5. Q 8 Superficial SSI Rate per Procedures CDC Benchmark Linear (Superficial SSI Rate per Procedures) Q3 Q Q 7 Q 7 Q3 7 Q 7 SSI Rate per Procedures CDC Benchmark=. Linear (SSI Rate per Procedures) Q Q3 Q Deep/Organ Space SSI Q 7 Q 7 Q3 7 Q 7.7 Q 8 SSI Rate per Procedures CDC Benchmark Linear (SSI Rate per Procedures)

4 C-Sections Preponderance of cases in morbidly obese patients Focus on wound care management Began silver dressings in March Noted a small decrease for March and April Will continue to monitor

5 Abd Hyst Details Q 7 Overall ABD Hyst SSI Q Q3 Q Q 8 SSI Rate per Procedures CDC Benchmark=.3 Linear (SSI Rate per Procedures) Superficial Abdominal Hysteretomy SSI Q 7 Q 7 Q3 7 Q 7 Q 8 Superficial SSI Rate per Procedures CDC Benchmark Linear (Superficial SSI Rate per Procedures) Deep/Organ Space Abd Hyst SSI Q 7 Q 7 Q3 7 Q 7 Q 8 SSI Rate per Procedures CDC Benchmark Linear (SSI Rate per Procedures) 3.3

6 Vaginal Hyst Details 8 Overall Vag Hyst SSI 9. Q 7 Q 7 Q3 Q Q 8 SSI Rate per Procedures CDC Benchmark=. Linear (SSI Rate per Procedures) Superficial SSI Q 7 Q 7 Q3 Q Q 8 SSI Rate per Procedures CDC Benchmark Linear (SSI Rate per Procedures) Deep/Organ Space Vag Hyst SSI Q 7 Q 7 Q3 7 Q 7 Q 8 SSI Rate per Procedures CDC Benchmark Linear (SSI Rate per Procedures) 9.

7 Hysterectomy No superficial deep infections vaginal hyst abd hyst Low denominators

8 MCE ORs

9 ColoRectal, by Quarter Superficial SSI Overall SSI Q 7 Q 7 Q3 7 Q 7 Q 8 Superficial SSI Rate per Procedures CDC Benchmark (5.%) Linear (Superficial SSI Rate per Procedures) 5 Deep/Organ Space SSI 5 Q 7 Q 7 Q3 7 Q 7 Q 8 SSI Rate per Procedures CDC Benchmark=5. Linear (SSI Rate per Procedures) 8 8 Q 7 Q 7 3Q 7 Q 7 Q 8 SSI Rate per Procedures CDC Benchmark (5.%) Linear (SSI Rate per Procedures).3

10 Colorectal Cases Using ICD-9 codes for CDC defined cases Looking at preoperative processes including bowel preps and home skin preparation

11 Main OR

12 Hip Prosthesis By Quarter Superficial SSI Overall SSI Q 7 Q 7 Q3 7 Q 7 Q 8 SSI Rate per Procedures CDC Benchmark=.5 Linear (SSI Rate per Procedures) Q 7 Q 7 Q3 7 Q 7 Q Superficial SSI Rate per Procedures CDC Benchmark Linear (Superficial SSI Rate per Procedures) Deep/Organ Space SSI Q 7 Q 7 Q3 7 Q 7 Q 8 SSI Rate per Procedures CDC Benchmark Linear (SSI Rate per Procedures)

13 Knee Prosthesis by Quarter Superficial SSI Overall SSI Q 7 Q 7 Q3 7 Q 7 Q 8 Superficial SSI Rate per Procedures CDC Benchmark Linear (Superficial SSI Rate per Procedures) Deep/Organ Space SSI.5 Q 7 Q 7 Q3 7 Q 7 Q 8 SSI Rate per Procedures CDC Benchmark=. Linear (SSI Rate per Procedures) Q 7 Q 7 Q3 7 Q 7 Q 8 SSI Rate per Procedures CDC Benchmark Linear (SSI Rate per Procedures)

14 Vascular by Quarter Superficial SSI Overall SSI Q 7 Q 7 Q3 7 Q 7 Q 8 Superficial SSI Rate per Procedures CDC Benchmark Linear (Superficial SSI Rate per Procedures) Deep/Organ Space SSI Q 7 Q 7 Q3 7 Q 7 Q 8 SSI Rate per Procedures CDC Benchmark=.3 Linear (SSI Rate per Procedures) Q 7 Q 7 Q3 7 Q 7 Q 8 SSI Rate per Procedures CDC Benchmark Linear (SSI Rate per Procedures)

15 Vascular Low denominators cases in Jan and cases in March Jan cases had one superficial and one deep Mar cases had one superficial and one deep

16 Craniotomy by Quarter Superficial SSI 8 Overall SSI Q 7 Q 7 Q3 7 Q 7 Q 8 Superficial SSI Rate per Procedures CDC Benchmark Deep/Organ Space SSI Q 7 Q 7 Q3 7 Q 7 Q 8 SSI Rate per Procedures CDC Benchmark= Q 7 Q 7 Q3 7 Q 7 Q 8 SSI Rate per Procedures CDC Benchmark

17 Craniotomies Prolonged cases CSF leaks Slowly trending down Trauma included 3:9 were trauma

18 Cardiac Procedures Adults By Quarter and OR Cardiac SSIs rate per procedures 8 Q - 7 Q 3Q Q Q - 8 MOR HYB CDC CDC benchmark=.5

19 CABG Minimally Invasive By Quarter and OR CABG (minimally invasive) Chest Infections rate per procedures Q - 7 Q 3Q Q Q - 8 CDC benchmark= MOR HYB CDC

20 CABG (both incisions) Leg Infections By Quarter and OR CABG (both incision sites) Leg Infections By Quarter and OR rate per procedures 8 Q - 7 Q 3Q Q Q - 8 MOR HYB CDC CDC benchmark =.

21 CABG (both incisions) Chest Infections By Quarter and OR CABG (both incision sites) Chest Infections By Quarter and OR rate per procedures 8 Q - 7 Q 3Q Q Q - 8 MOR HYB CDC 5. CDC benchmark=

22 VCH ORs

23 VCH VP Shunts, by Quarter Superficial SSI 5 5 Overall SSI VCH VP Shunts. Q 7 Q 7 Q3 7 Q 7 Q 8 SSI Rate per Procedures CDC Benchmark=5. Linear (SSI Rate per Procedures) Q 7 Q 7 Q3 7 Q 7 Q 8 Superficial SSI Rate per Procedures CDC Benchmark Linear (Superficial SSI Rate per Procedures) Deep/Organ Space SSI.5 3. Q 7 Q 7 Q3 7 Q 7 Q 8 SSI Rate per Procedures CDC Benchmark Linear (SSI Rate per Procedures)

24 VP Shunts Trending up Begin to explore skin prep

25 Cardiac Infections (primary incision closed) By Quarter Fig. Cardiac surgical site infections, by quarter rate per procedures 5 3 Q 7 Q 3Q Q Q 8 * Incomplete quarter VCH rate =. (8/39) CDC Risk =.5 VCH Rate CDC Risk Mean Linear (VCH Rate)

26 Cardiac Infections (delayed sternal closures) By Quarter G-Chart: Days Between Infections Higher is Better G-Chart Delayed Sternal Closures By Month of Onset Days between infection J F F A A A S O N N N J J J M Days Betw een Infection Average = 8. 3 SDV =. 5 days between last two (DSC) infections

27 TOSHA Consultative Branch TOHSA Consultation Branch conducted a survey of VUH April - They visited Main OR, MCE, s ORS, Holding Rooms, PACU as well as ED, ICUs including BURN, Trauma, SICU, CVICU, and LifeFlight They found a cystotome needle (for eye irrigation during cataract surgery) while in MCE. This device was NOT on the waivered sharps list Classed as a non-serous hazard No written Corrective Action Plan needed They observed surgery in MCE, Main OR, and South They were impressed with the safety program overall

28 EOC Survey Findings MOR Surveyed April 8, 8 Surveyed May, 8 Repeat survey May 5, 8 VCH Surveyed May 3, 8

29 Expired IV Bags in Main Core Expired IV bags found in Main OR Core Apr 8 and May No expired bags found May 5.

30 Pyxis Refrigerator Main OR Core Pyxis Refrigerator in Main OR Core with unidentified liquid dripping Cleaned May 5.

31 Dirty Knee Positioners Main OR Knee positioners dirty in ortho OR rooms Unable to re-survey on May 5

32 Harmonic Scalpel with Blood and Betadine Main OR Dirty equipment Ready for use Clean on May 5 resurvey

33 VCH EOC Survey May 3 unsecured E oxygen cylinders Extremely clean throughout No expired fluids or meds All equipment was clean and without blood or betadine splatter