外科监护治疗改良方案 surgical care improvement project课件

SurgicalSiteInfectionsTheMedicareQualityImprovementOrganizationforArizona WhatisSCIP SurgicalCareImprovementProjectEvolvedfromSIPEncompassesadditionalaspectsofsurgicalcareReduce prevent Cardiacevents emboli andventilator associatedpneumonia OpportunitiestoImproveCare SSI occursin14 16 surgicalpatients40 60 ofSSIsarepreventableCardiac 2 5 noncardiacsurgery 34 invascular AMImortalityrateashighas70 DVT PE withoutprophylaxis generalsurgerycases25 7 orthopediccases 50 DVT 30 PEVAP occurs9 40 withassociatedmortalityratesof30 46 SCIPGoals Reducepostoperativemortalityandmorbidityby25 over5years ACloserLookatSSI SSIina51 caseday7 65patientsatriskforinfection4 59ofthoseinfectionsarepreventable InsertOrganizationalData SCIPintheNews Newsweek December12 20056KeystoSaferHospitalsUSATodayABCNews20 20MoreKilledAnnuallyThanbyAutoAccidentsandHomicides 10 14 2005 SCIPSupport AmericanCollegeofSurgeonsAmericanSocietyofAnesthesiologyAmericanHospitalAssociationCDCJCAHOAORNVeteransAdministrationAHRQ EvidenceBased Evidence basedmedicineistheprocessofsystematicallyfinding appraising andusingcontemporaneousresearchfindingsasthebasisforclinicaldecisions Evidence basedmedicineisaboutaskingquestions findingandappraisingtherelevantdata andharnessingthatinformationforeverydayclinicalpractice BMJ1995 310 1122 1126 29April WilliamRosenberg AnnaDonaldEvidence basedMedicine AnApproachtoClinicalProblem solving SSIQualityMeasures 1 Prophylacticantibioticreceivedwithin1hourpriortosurgicalincision2 Prophylacticantibioticselectionforsurgicalpatients3 Prophylacticantibioticsdiscontinuedwithin24hoursaftersurgeryendtime 48hoursforcardiacpatients 4 Cardiacsurgerypatientswithcontrolled6a m postoperativeserumglucose SSIQualityMeasures 5 Postoperativewoundinfectiondiagnosedduringindexhospitalization6 Surgerypatientswithappropriatesurgicalsitehairremoval7 Colorectalsurgerypatientswithimmediatepostoperativenormothermia VTEQualityMeasures 1 Surgerypatientswithrecommendedvenousthromboembolismprophylaxisordered2 Surgerypatientswhoreceivedappropriatevenousthromboembolismprophylaxis within24hourspriortosurgeryto24hoursaftersurgery3 Intra orpostoperativepulmonaryembolism PE diagnosedduringindexhospitalizationandwithin30daysofsurgery4 Intra orpostoperativedeepveinthrombosis DVT diagnosedduringindexhospitalizationandwithin30daysofsurgery VAPQualityMeasures 1 Numberofdaysventilatedsurgerypatientshaddocumentationoftheheadofthebed HOB beingelevated fromrecoveryenddate dayzero throughpostoperativedayseven 2 Patientsdiagnosedwithpostoperativeventilator associatedpneumonia VAP duringindexhospitalization3 Numberofdaysventilatedsurgerypatientshaddocumentationofstressulcerdisease SUD prophylaxis fromrecoveryenddate dayzero throughpostoperativedayseven 4 Surgerypatientswhosemedicalrecordcontainedanorderforaventilator weaningprogram protocolorclinicalpathway CardiacQualityMeasures 2 Surgerypatientsonabeta blockerpriortoarrivalthatreceivedabeta blockerduringtheperioperativeperiod3 Intra orpostoperativeacutemyocardialinfarction AMI diagnosedduringindexhospitalizationandwithin30daysofsurgery Arizona sRanking BeforeSCIP AlcoholscrubsMostrapidreductionofbacteriacounts1minute 4 7minutesofotheragentsTransferof1 000organismsBacterialsurvival20 150minutesVirussurvival20 30minutesChaptersfromACSSurgeryPreventionofPostoperativeInfectionJonathanL Meakins M D D Sc F A C S Impact Pairsmatchedforprocedure NNISindex age Generalinpatientsurgicalpopulation 22 742proceduresincludedKirkland InfectControlHospEpidemiol 1999 20 725 Prospective case controlledstudyof22 742patientsundergoinginpatientsurgicalproceduresbetween1991 1995 InformationadaptedfromtheInstituteforHealthcareImprovement www ihi org Opportunity DecreasingtherateofSSIisanopportunityto ImprovecarePromoteimprovedoutcomesIncreasepatientsatisfactionReducecosts ComponentsofSSI AntibioticAdministrationHairRemovalGlucoseControlNormothermia CATS Clipping HairRemoval AntibioticAdministrationThermia Normothermia Sugar GlucoseControl Antibiotics TimelyadministrationSelectionTimelydiscontinuation TimelyAdministration Moststudiesindicatethatoptimumtimingforprophylacticantibioticiswithin1hourofincisiontime Cephalosporins Whencuffisused makesureallantibioticisinfusedpriortoinflationofcuff Note Becauseofthelongerrequiredinfusiontime vancomycin whenindicatedforbeta lactamallergy shouldbestartedwithin2hoursbeforetheincision InformationadaptedfromtheInstituteforHealthcareImprovement www ihi org TimingofAbx Prophylaxis Classen etal NEnglJMed 1992 328 281 InformationadaptedfromtheInstituteforHealthcareImprovement www ihi org InsertOrganizationalData AntibioticSelection ChooseprophylacticantibioticsconsistentwithnationalguidelinesSpecialcases Allergy anaphylactoid to lactamantibioticsHighrateofMRSAwoundinfectionslocallyRecentprolongedcourseofantibioticsorICUstay InformationadaptedfromtheInstituteforHealthcareImprovement www ihi org Ancef CefazolinEffectiveagainstgrampositiveandnegativeLowrateofallergicresponsesEasytoadministerInexpensive ProphylaxisDosing Alwaysgiveatleastafulltherapeuticdoseofantibiotic Considertheupperrangeofdosesforlargepatientsand orlongoperations Repeatdosesforlongoperations 4hours InformationadaptedfromtheInstituteforHealthcareImprovement www ihi org ProphylaxisDuration Moststudieshaveconfirmedefficacyof 12hrs Manystudieshaveshownefficacyofasingledose Whenevercompared theshortercoursehasbeenaseffectiveasthelongercourse Thereisnoneedtocontinuecoveragebeyond24hours InformationadaptedfromtheInstituteforHealthcareImprovement www ihi org DurationConcerns AntibioticprophylaxisisoneofmanymethodsforreducingtheincidenceofSSI ThereisalackofevidencethatantibioticsgivenaftertheendoftheoperationpreventSSIs Thereisevidencethatunnecessaryorprolongeduseofantibioticspromotesantibioticresistance InformationadaptedfromtheInstituteforHealthcareImprovement www ihi org Tubes Lines andDrains Medicalliteraturedoesnotsupportthecontinuationofantibioticsuntilalldrainsorcathetersareremovedandprovidesnoevidenceofbenefitwhentheyarecontinuedpast24hours AdvisoryStatement RecommendationsfortheUseofIntravenousAntibioticProphylaxisinPrimaryTotalJointArthroplastyAmericanAssociationofOrthopedicSurgeons AAOS DurationinCardiacSurgery OurfindingsconfirmthatcontinuingABPbeyond48hoursafterCABGsurgeryisstillwidespread however thispracticeisineffectiveinreducingSSI increasesantimicrobialresistance andshouldthereforebeavoided ProlongedAntibioticProphylaxisAfterCardiovascularSurgeryandItsEffectonSurgicalSiteInfectionsandAntimicrobialResistanceStephanHarbarth MD MS MatthewH Samore MD DebiLichtenberg RN YehudaCarmeli MD MPHCirculation 2000 101 2916 2921 InsertOrganizationalData HairRemovalQualityMeasure Surgerypatientswithappropriatesurgicalsitehhairremoval HairRemoval Appropriate NohairremovalatallClippingDepilatoryuseInappropriate Razors InformationadaptedfromtheInstituteforHealthcareImprovement www ihi org ShavingInfluence NoHairGroupRemovalDepilatoryShavedNumber155153246Infectionrate0 6 0 6 5 6 Seropian AmJSurg 1971 121 251 InformationadaptedfromtheInstituteforHealthcareImprovement www ihi org GlucoseControl Cardiacsurgerypatientswithcontrolled6 00a m postoperativeserumglucose Themeasurelooksattheglucoseresultforpostoperativeday1andday2 Risk GlucoseControl CardiacSurgery Increasedrisk DiagnoseddiabetesUndiagnoseddiabetesPost opglucose 200mg within48hLatham InfContrHospEpidemiol 2001 22 607 Dellinger InfContrHospEpidemiol 2001 22 604 SSIRelatedtoGlucoseControl CardiacSurgeryafterMedianSternotomyLatham ICHE 2001 22 607 612 InformationadaptedfromtheInstituteforHealthcareImprovement www ihi org AdditionalBenefitsofGlucoseControl Decreased AcuterenalfailureRedcelltransfusionsVentilatorsupportTimespentinintensivecarevandenBergheG WoutersP WeekersF etal Intensiveinsulintherapyinthecriticallyillpatients NEnglJMed 2001Nov 8 345 19 1359 1367 PMID 11794168 NormothermiaQualityMeasure Colorectalsurgerypatientswithimmediatenormothermia 96 8 100 4 F withinthefirsthourafterleavingtheoperatingroom Normothermia Patientswhohadadecreaseofonly1 9 Cincoretemperaturewerethreetimesaslikelytodevelopsurgicalwoundinfectionsaswerethoseinwhomanormalbodytemperatureof37 Cwasmaintained KurzA SesslerDI LenhardtRA Perioperativenormothermiatoreducetheincidenceofsurgical woundinfectionandshortenhospitalization NEnglJMed1996 334 1209 15 BeAnAdvocate Advocatetoreducetheriskof