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Post-operative Care · The SHEA Podcast

• 0:06
  SPEAKER_01: Welcome to the updates from the SSI Compendium Podcast Series brought to you by the Society for Healthcare Epidemiology of America, SHAI, promoting the prevention of healthcare associated infections and antibiotic resistance and seeking to advance the field of healthcare epidemiology and antibiotic stewardship.
• 0:23
  SPEAKER_01: I'm Dr.
• 0:23
  SPEAKER_01: Jessica Howard Anderson, Assistant Professor of Medicine at Emory University School of Medicine and the Associate Hospital Epidemiologist at our Emory University Midtown Hospital, and I will serve as today's moderator.
• 0:34
  SPEAKER_01: She's excited to launch this final episode of the updates from the SSI compendium, post-operative care.
• 0:41
  SPEAKER_01: In this episode, we will discuss the major recommendations included in the Chine SSI compendium that address the post-operative period.
• 0:48
  SPEAKER_01: We will specifically focus on the recommendations regarding blood glucose control, discontinuing perioperative antibiotics after incisional closure, and providing feedback.
• 0:58
  SPEAKER_01: I'm happy to introduce our speakers for today.
• 1:00
  SPEAKER_01: First, we have Dr.
• 1:01
  SPEAKER_01: Michael Calderwood.
• 1:03
  SPEAKER_01: Dr.
• 1:03
  SPEAKER_01: Calderwood serves as Chief Quality Officer for Dartmouth Hitchcock Medical Center, where he oversees safety, quality, patient experience, process improvement, and regulatory compliance.
• 1:14
  SPEAKER_01: He's an associate professor of medicine at the Geisel School of Medicine at Dartmouth, and he's a staff physician in the section of infectious diseases and international health.
• 1:22
  SPEAKER_03: Happy to be here.
• 1:23
  SPEAKER_01: Thanks, Michael.
• 1:24
  SPEAKER_01: Next, we have Dr.
• 1:26
  SPEAKER_01: Patchin Dellinger, known as Patch, who trained in surgery in Boston in the 70s and did an ID fellowship with Lou Weinstein during his research years.
• 1:35
  SPEAKER_01: He then moved to the University of Washington, where he's been there for 46 years, focusing on the prevention, diagnosis, and treatment of surgical infections.
• 1:43
  SPEAKER_01: He participated in both the WHO and CDC SSI prevention guidelines.
• 1:48
  SPEAKER_02: Hi, everybody.
• 1:49
  SPEAKER_02: Glad to be here with my colleagues.
• 1:51
  SPEAKER_01: Thanks so much, Pat.
• 1:53
  SPEAKER_01: And finally, we have Dr.
• 1:54
  SPEAKER_01: Joshua Shamson.
• 1:56
  SPEAKER_01: Dr.
• 1:56
  SPEAKER_01: Shamson is a pediatric infectious diseases physician based in Ottawa, Ontario, Canada.
• 2:01
  SPEAKER_01: His experience in healthcare epidemiology and implementation includes time spent in public health as a clinical hospitalist and as a director of the infection prevention and control program at Cincinnati Children's Hospital Medical Center.
• 2:14
  SPEAKER_01: A longtime SHA member, Josh has served on the Guidelines Committee, Pediatric Leadership Council, and the SHA Conference Planning Committee.
• 2:21
  SPEAKER_01: He co-led the writing group for the 2022 Compendium Implementation Chapter and was on the SSI chapter writing panel as well.
• 2:29
  SPEAKER_00: Hi, thanks for having me.
• 2:30
  SPEAKER_01: Thanks so much, Jamsh, and thank you all for joining us today.
• 2:34
  SPEAKER_01: So I'm excited for this conversation and we'll jump on in.
• 2:38
  SPEAKER_01: Patch, I'd like to turn to you first.
• 2:40
  SPEAKER_01: I know you were an author on the prior 2014 SHA SSI prevention guidance and have been part of other SSI guideline committees as well.
• 2:48
  SPEAKER_01: So can you start with putting these guidelines into context for us and mention what you think are the key postoperative recommendations in this SSI compendium update?
• 2:57
  SPEAKER_02: Yes, I have been involved in many guidelines over the years, certainly including the 2014 compendium from SHA, updated this year, both of them in Itchy, and also worked on the WHO, the CDC guidelines, a combined one with the American College of Surgeons and the Surgical Infection Society.
• 3:20
  SPEAKER_02: And they're all pretty consistent with one another for the most part.
• 3:25
  SPEAKER_02: The one thing that has changed a bit is that until a few years ago, most of the guidelines acknowledged or approved the administration of prophylactic antibiotics continuing for as long as 24 hours after operation is over.
• 3:43
  SPEAKER_02: And the recent update of the compendium recommends stopping when the incision is closed.
• 3:50
  SPEAKER_02: And this is also consistent with guidelines from WHO and CDC.
• 3:55
  SPEAKER_02: In terms of other post-operative recommendations, there's a section on controlling glucose, both in diabetic and non-diabetic patients, surveillance for SSI, and feedback to the clinical teams, and the use of negative pressure wound therapy dressings for some cases.
• 4:16
  SPEAKER_01: Great.
• 4:19
  SPEAKER_01: And thanks for putting this update into the context of the previous and other additional guidelines that are out there on SSI.
• 4:26
  SPEAKER_01: So I'd like to take a deeper dive now into the decision you mentioned on controlling blood glucose levels.
• 4:32
  SPEAKER_01: The guidance actually says to control blood glucose levels between 110 to 150 in the immediate post-operative period.
• 4:39
  SPEAKER_01: Michael, can you walk us through how this guidance was determined?
• 4:43
  SPEAKER_03: Absolutely.
• 4:43
  SPEAKER_03: So thank you, Jessica.
• 4:45
  SPEAKER_03: It's been a number of years since we had the prior compendium that was put out by uh Sheng and partner organizations.
• 4:52
  SPEAKER_03: And so if you look at the evidence that's come out between 2014 and the 2022 guideline, there really has been a bunch of new data about the management of blood glucose in the immediate posto-operative period.
• 5:06
  SPEAKER_03: And there have also been a number of interval guidelines that have looked at that.
• 5:10
  SPEAKER_03: And we wanted to make sure that we were looking at the same evidence and trying to find that alignment.
• 5:16
  SPEAKER_03: We don't wanted people looking at different documents and saying, well, why does one suggest this range and the other suggest something different?
• 5:23
  SPEAKER_03: And so Patch had referenced that in 2016 the American College of Surgeons and the Surgical Infection Society had published their own SSI prevention guidelines, and they had reached a consensus on short-term perioperative glucose control in the 110 to 150 milligrams per deciliter range, and showing that that had significant impact in reducing rates of surgical site infection.
• 5:49
  SPEAKER_03: And in that guideline, there were 14 provided references that we also uh looked to.
• 5:55
  SPEAKER_03: There were multiple prospective randomized control trials.
• 5:58
  SPEAKER_03: And if you actually look at the ranges, they range from about 100 to 150 milligrams per deciliter.
• 6:05
  SPEAKER_03: And most guidelines have opted to trim off that bottom range because there is some evidence that if you're controlling too aggressively and getting people less than 110 milligrams per deciliter in that postoperative period, that you might overshoot.
• 6:21
  SPEAKER_03: And there is a risk of significantly lowering blood glucose level with increased risk of stroke and death.
• 6:28
  SPEAKER_03: So we're moving away from the prior range of less than 200, less than 180, really targeting that 110 to 150.
• 6:35
  SPEAKER_03: Now, the other thing that's new here is that it's not just in patients with known diabetes.
• 6:41
  SPEAKER_03: And there's a lot of patients both with unknown diabetes, prediabetes, or because of the stress of surgery or medical therapies they're given, at risk for perioperate hyperglycemia.
• 6:53
  SPEAKER_03: And it actually has been shown that there's a greater risk from hyperglycemia in non-diabetics than in diabetics.
• 7:00
  SPEAKER_03: And so this is worth thinking about the totality of all patients, not just those with known diabetes.
• 7:05
  SPEAKER_03: And there was a nice paper in JAMA.
• 7:07
  SPEAKER_03: It was kind of an insights article back in 2020 that was looking at the differences between the different SSI guidelines.
• 7:14
  SPEAKER_03: They compared the ACS-SIS guidelines with the WHO guidelines, with the CDC guidelines.
• 7:19
  SPEAKER_03: And this was an area where there continued to be differing recommendations.
• 7:24
  SPEAKER_03: So as our group kind of went back and looked at things, we anchored on some really significant studies I want to highlight.
• 7:32
  SPEAKER_03: One is, and Patrick will talk about this a little bit more, but a 2013 retrospective study by Kwan et al.
• 7:39
  SPEAKER_03: that really looked at perioperative glucose management for close to 12,000 patients, and also a 2018 meta-analysis that had 15 randomized control trials with over 5,000 patients.
• 7:52
  SPEAKER_03: And both of these really showed the benefit of this tight glycemic control, both for the reduction in SSI and some evidence that it also improved short-term mortality.
• 8:02
  SPEAKER_03: And so that really was what anchored us in coming forward with this recommendation.
• 8:06
  SPEAKER_03: The last thing I'll say is we had a lot of debate about what do we mean by the perioperative period.
• 8:11
  SPEAKER_03: And most studies looked at control in the two days post-operative.
• 8:16
  SPEAKER_03: So post-operative day one and two.
• 8:19
  SPEAKER_03: We don't know if control beyond that period will also be beneficial, but our recommendation was really focusing in those first two postoperative days.
• 8:28
  SPEAKER_01: Thank you, Michael.
• 8:29
  SPEAKER_01: I think that was an incredibly helpful explanation.
• 8:32
  SPEAKER_01: Patch, I believe you have experience developing a peroperative glucose algorithm at the University of Washington.
• 8:38
  SPEAKER_01: So could you tell us a little bit about this and any challenges you faced with the implementation?
• 8:43
  SPEAKER_02: Oh, yeah, there are plenty of challenges.
• 8:46
  SPEAKER_02: Well, I got really interested in this when I saw an article in Itchy in uh 2001, which focused in that time on cardiac surgery and showed that high glucose was associated with high complication rate.
• 9:01
  SPEAKER_02: And when I read it carefully, I found that 47% of all patients with high blood sugars and poor outcomes were not diabetic.
• 9:11
  SPEAKER_02: And I wrote an editorial about it at the time, and I got very interested in this and started talking to my general surgery group about it.
• 9:19
  SPEAKER_02: And one of my colleagues, who focuses a lot on outcomes research, said, All right, enough talk.
• 9:25
  SPEAKER_02: Let's get a program started in our institution.
• 9:29
  SPEAKER_02: And so I reached out and talked with a number of different people in different areas and specialties, and we gathered basically a working group with endocrinologists, pharmacists, anesthesiologists, surgeons, and operating room nurses, and put together a concept that began with testing every patient who comes to the OR, regardless of diagnosis, for their fasting blood glucose when they arrive in pre-op holding before going to the operating room.
• 10:00
  SPEAKER_02: And then we developed a protocol for if the blood sugar was above 140 to start insulin.
• 10:08
  SPEAKER_02: And we developed, again, this working group, this multidisciplinary working group, put together an algorithm.
• 10:15
  SPEAKER_02: And we have an algorithm with nine different protocols within it, depending on the degree of hyperglycemia and the amount of insulin being used.
• 10:25
  SPEAKER_02: And we started the program that you would start, once you got to the operating room, the anesthesiologist after induction would again check blood sugars within the first 45 to 90 minutes after incision, and again use this protocol, if necessary, in the operating room to control blood sugars.
• 10:46
  SPEAKER_02: We were also one of the hospitals in the world that began using the checklist a number of years before this, and we added the checking of blood sugars in the operating room as part of our surgical safety checklist.
• 11:02
  SPEAKER_02: And I remember when we started this, I would be doing the checklist and ask the anesthesiologist, what is the patient's blood sugar?
• 11:09
  SPEAKER_02: And a common answer at the beginning of this was, why do you care?
• 11:13
  SPEAKER_02: The patient's not diabetic.
• 11:15
  SPEAKER_02: And over time, this kind of thing improved.
• 11:19
  SPEAKER_02: And I would say that we have become better and better at controlling interoperative blood sugars in the University of Washington.
• 11:28
  SPEAKER_02: And we've done a number of investigations of this, many of them published.
• 11:33
  SPEAKER_02: And most recently, we found that during the year of 2016, among 3,526 patients getting insulin in the operating room, we had only four patients that ever experienced the blood sugar below 70.
• 11:50
  SPEAKER_02: And those four patients had no symptoms and had no side effects or problems with that.
• 11:57
  SPEAKER_02: So the risk of a hypoglycemia under 70 using our protocol in the University of Washington is 0.0011.
• 12:08
  SPEAKER_02: Our target is 100 to 140, and as Michael mentioned, the recommendation in the compendium and by WHO is up 110 to 150.
• 12:19
  SPEAKER_02: As long as you're careful, small differences don't make a huge difference.
• 12:24
  SPEAKER_02: The other thing we have is an interdisciplinary group that meets, we used to meet monthly, we now meet every two to three months to discuss how things are going in the operating room, what problems have evolved, who is unhappy with what's going on, how do we deal with that?
• 12:42
  SPEAKER_02: Do we need any changes in our protocols, and so on?
• 12:45
  SPEAKER_02: And I think we've been gradually getting better and better over the years.
• 12:50
  SPEAKER_01: Thank you, Patch.
• 12:51
  SPEAKER_01: That's really interesting to hear about your experience.
• 12:54
  SPEAKER_01: And it sounds like you've had a lot of great successes.
• 12:57
  SPEAKER_01: Josh, I know you have expertise in implementation, and there are obviously a lot of potential challenges with implementing a perioperative glucose regimen.
• 13:07
  SPEAKER_01: So can you discuss some of the implementation challenges and possible strategies to overcome this?
• 13:12
  SPEAKER_00: Yeah, thanks.
• 13:13
  SPEAKER_00: And thanks for that story, Patch.
• 13:15
  SPEAKER_00: I think it illustrates a lot of different challenges and the way you overcome it, really, by continuing to work at things, talk through things, and come to consensus.
• 13:23
  SPEAKER_00: I think in terms of challenges and things I would call out, there are three things that I would think about in this type of implementation question.
• 13:32
  SPEAKER_00: The first is that, as in any implementation effort, you should take time to understand the determinants of an outcome.
• 13:39
  SPEAKER_00: So what are the facilitating factors?
• 13:41
  SPEAKER_00: What are the barriers to successful execution?
• 13:44
  SPEAKER_00: So when you're talking about postoperative blood glucose monitoring or interoperative blood glucose monitoring, you need to consider logistics around testing.
• 13:53
  SPEAKER_00: So is the unit accustomed to testing?
• 13:55
  SPEAKER_00: Do they have the right equipment?
• 13:56
  SPEAKER_00: Do they have the right training with it?
• 13:58
  SPEAKER_00: You need medication.
• 13:59
  SPEAKER_00: Do you have insulin?
• 14:00
  SPEAKER_00: Can you get insulin?
• 14:01
  SPEAKER_00: Who gets insulin?
• 14:02
  SPEAKER_00: How do they dose it?
• 14:03
  SPEAKER_00: Monitoring, and then of course documentation because you want to know that you're doing what you think you're doing.
• 14:09
  SPEAKER_00: Um, what you want to do is you want to try to determine where the care is happening and what the current capacity for blood glucose monitoring and maintenance is so that you can set a goal of what you're going to try to achieve.
• 14:21
  SPEAKER_00: You can't assume that every unit functions in the same way.
• 14:25
  SPEAKER_00: Every unit is going to be different.
• 14:27
  SPEAKER_00: And that leads me to my second point, which is using the lean methodology principle of going to the Gemba, so going to the location, go see and ask why.
• 14:38
  SPEAKER_00: And so the recommendation would be to go directly to where the care is happening and get input from the stakeholders and observe the processes.
• 14:45
  SPEAKER_00: Ask them how difficult would it be to do this?
• 14:48
  SPEAKER_00: How far in is this?
• 14:49
  SPEAKER_00: When you think about safety and you think about inpatients, often a patient will receive a certain type of care on a given unit that's very experienced with that care.
• 14:59
  SPEAKER_00: And if you take that patient to another unit that's less experienced, that second unit is very uncomfortable.
• 15:05
  SPEAKER_00: And we call that a fish out of water.
• 15:07
  SPEAKER_00: And so what you're looking for is what are the water conditions as you bring your blood glucose fish to them.
• 15:14
  SPEAKER_00: And then the last thing that I would call out is that any practice change is going to involve education or training of some kind.
• 15:22
  SPEAKER_00: And I would urge people to remember that education is a low reliability intervention.
• 15:26
  SPEAKER_00: So it's essential, but it's not sufficient to change practice.
• 15:30
  SPEAKER_00: So what you want to look for is you want to look for ways to collaborate, look for ways to automate the process, to remove the requirement for extensive knowledge or for remembering education that you may have had months ago.
• 15:44
  SPEAKER_00: Because healthcare personnel are very busy and their tasks involve a considerable amount of mental energy.
• 15:51
  SPEAKER_00: And introducing something new that doesn't demand even more energy is more likely to achieve your desired outcome.
• 15:59
  SPEAKER_01: Thanks, Josh.
• 16:00
  SPEAKER_01: All really important points.
• 16:01
  SPEAKER_01: So another postoperative recommendation that is included that might be challenging to implement is the recommendation to discontinue antimicrobial agents after incisional closure in the operating room.
• 16:13
  SPEAKER_01: Michael, can you talk about the discussion that went into this recommendation and your experience with implementing this recommendation?
• 16:20
  SPEAKER_03: Absolutely.
• 16:21
  SPEAKER_03: This is this is another area where the strength of the data has continued to grow since the 2014 compendium.
• 16:28
  SPEAKER_03: And really, it's not all that controversial if you look at how this aligns with a number of recommendations that have come out in the interim.
• 16:37
  SPEAKER_03: And I just want to highlight that.
• 16:39
  SPEAKER_03: This recommendation of stopping antibiotics at the time of skin closure is actually aligned with the 2017 CDC guidelines for SSI prevention, 2018 WHO guidelines for SSI prevention.
• 16:53
  SPEAKER_03: And even within the 2016 ACS and SIS guidelines, they really write that with rare exception, antibiotics should be stopped at the time of skin closure.
• 17:04
  SPEAKER_03: Now, those guidelines did call out some areas like implant-based breast reconstruction, joint arthroplasty, and cardiac procedures where they thought the optimal duration may not be known.
• 17:15
  SPEAKER_03: So we went a little bit further to really say all inclusive, and I'll highlight why we felt we could get to that point.
• 17:22
  SPEAKER_03: But this is an area that after you know our compendium document came out, there continues to be some discussion about are there niche areas where we need to continue to gather the data and bring our colleagues along.
• 17:36
  SPEAKER_03: Now, you know, what I will say is I'll just start with the headline.
• 17:40
  SPEAKER_03: Antibiotics that are administered before and during surgery as part of prophylaxis to prevent surgical site infection should be discontinued immediately after the patient's incision is closed.
• 17:54
  SPEAKER_03: That's regardless of whether a drain is in place, and that there's no evidence that continuing antibiotics after the incision has been closed is associated with a lower rate of surgical site infection.
• 18:06
  SPEAKER_03: In fact, it's actually associated with harm.
• 18:09
  SPEAKER_03: And we have data suggesting that there's increased risk of C.
• 18:13
  SPEAKER_03: defaceal infection, of acute kidney injury, and rising antimicrobial resistance.
• 18:19
  SPEAKER_03: No benefit, clear harm.
• 18:21
  SPEAKER_03: Now, if you look at kind of what's coming out, the surgeons are really coming around to this.
• 18:26
  SPEAKER_03: There was a wonderful surgical perspective published in the Journal of the American College of Surgeons in 2020 that was entitled Surgeons as Antimicrobial Stewards.
• 18:36
  SPEAKER_03: Now the authors in this article wrote for clean and clean contaminated incisions, antibiotics given after incision closure have no impact on further reducing SSI risk.
• 18:47
  SPEAKER_03: Therefore, antibiotics should not be administered after skin closure in these surgical cases, and they provide six references.
• 18:54
  SPEAKER_03: So this is the ACS really coming around what now is across multiple guidelines.
• 19:00
  SPEAKER_03: Now there are two papers that are worth kind of noting.
• 19:03
  SPEAKER_03: The first is the 2019 paper in JAMA surgery by Branch Elman and uh colleagues.
• 19:08
  SPEAKER_03: And the second is a 2022 paper in arthroplasty by Lee et al.
• 19:14
  SPEAKER_03: In the Branch Elman paper, this is a multi-center national retrospective cohort study.
• 19:20
  SPEAKER_03: It's a VA study, had over 79,000 patients, and very clearly showed that extended duration did not lead to additional SSI reduction, but did lead to harm.
• 19:30
  SPEAKER_03: We talked about that previously.
• 19:33
  SPEAKER_03: The Lee paper is interesting because this is written by a group of orthopedic surgeons.
• 19:38
  SPEAKER_03: This is a review, but it highlights and references four studies showing no reduced surgical site infection with prophylactics after skin closure in arthroplasty and spine procedures.
• 19:51
  SPEAKER_03: Orthopedic focused, NICE studies that were done, one by my colleagues here at Dartmouth Hitchcock Medical Center.
• 19:57
  SPEAKER_03: Now, people will say, well, my area doesn't yet have that level of evidence.
• 20:03
  SPEAKER_03: And you know, we just need to remind ourselves that the absence of evidence is not the evidence of absence.
• 20:09
  SPEAKER_03: And so we need to think about as we have more and more of these studies that are saying the same thing, we need to look at it for each individual patient population, each individual surgical group.
• 20:20
  SPEAKER_03: This is one where we actually used a drug shortage to help our surgeons come along in this space.
• 20:26
  SPEAKER_03: Um, so my predecessor, the uh chief quality officer of the role before me, who was a mentor of mine, used to say, never waste a good crisis.
• 20:34
  SPEAKER_03: We had a period where we had a national shortage of cefazolin and we weren't going to be able to give it to all of our surgical patients.
• 20:40
  SPEAKER_03: And so we said, is this the time that we can come around and say we're gonna stop at the time of skin closure?
• 20:46
  SPEAKER_03: And there was a lot of grumbling.
• 20:48
  SPEAKER_03: And but what actually happened was our orthopedic colleagues came forward and said, Yes, but can we study it?
• 20:53
  SPEAKER_03: We said, Absolutely, that's perfect.
• 20:55
  SPEAKER_03: Let's study it.
• 20:56
  SPEAKER_03: And they we did it, they studied it and said, Oh, wait, our patients didn't do worse.
• 21:00
  SPEAKER_03: Okay, we'll continue to do this.
• 21:01
  SPEAKER_03: And we were able to change practice driven by that shortage, but it allowed us to gather the evidence that brought people along with us.
• 21:08
  SPEAKER_01: Thank you, Michael.
• 21:09
  SPEAKER_01: I love that quote.
• 21:10
  SPEAKER_01: Never waste a good crisis.
• 21:12
  SPEAKER_01: Patch, from the surgery perspective, what challenges or concerns do you see in implementing this recommendation?
• 21:19
  SPEAKER_02: You know, it's it's the old thing, and I think Michael partly touched on this, but basically change is difficult.
• 21:26
  SPEAKER_02: And getting people to do something different from the way they were brought up in their residency or the way they've been practicing for the last five or ten years takes time and effort, and you need to just keep working at it.
• 21:40
  SPEAKER_02: There are a number of references that show if you look at a new medical knowledge that has grade one level evidence, and you look at whether this is applied in actual practice, the average time is about 17 years between.
• 22:00
  SPEAKER_02: The widely accepted knowledge about a process and its actual adoption.
• 22:07
  SPEAKER_02: And that's just the average.
• 22:08
  SPEAKER_02: So that means half of the people are continuing beyond 17 years.
• 22:13
  SPEAKER_02: So it just needs careful discussion and implementation in a surgical group, and it needs to try to convince some of the more prominent, respected surgeons to adopt a new practice and then work on showing their colleagues that it works.
• 22:33
  SPEAKER_02: When I lecture on prophylaxis, one of my slides says, what are the indications for antibiotics?
• 22:40
  SPEAKER_02: We assume it's because they're antibacterial, but sometimes it seems as if they're being used as antipyretics or perhaps as tranquilizers for the doctor, the nurse, the patient, the family.
• 22:54
  SPEAKER_02: And it just takes time to get these changes accomplished.
• 23:00
  SPEAKER_01: Thank you, Patch.
• 23:01
  SPEAKER_01: Josh, any additional thoughts?
• 23:03
  SPEAKER_00: I often will say when I'm talking to a provider who wants to give antibiotics, and they'll say, well, I'll just feel better if this patient got antibiotics for X amount of time.
• 23:12
  SPEAKER_00: And what I want to say is, you know what, it's about the patient feeling better.
• 23:16
  SPEAKER_00: It's not about you.
• 23:17
  SPEAKER_00: So the only thing I would add, and and this is uh very much what Patch was saying, is that few of us enjoy change, especially when it involves something we've been doing for a long time that we believe is important.
• 23:28
  SPEAKER_00: So as Patch said, people were trained that this is important.
• 23:31
  SPEAKER_00: And so if they have it's become a truth that post op antibiotics are important, the evidence saying otherwise, it's very hard for them to redirect and it's not going to be automatic.
• 23:42
  SPEAKER_00: So what I would say is that resistance to this type of change should be expected and acknowledged and should be countered both with data as well as empathy for the difficulty of change, right?
• 23:53
  SPEAKER_00: So that's the patients and bringing people along.
• 23:55
  SPEAKER_00: Waiting for a large RCT to show postoperative antibiotics are not needed in every situation and every subspecialty is not productive.
• 24:03
  SPEAKER_00: Rather, providing data, maybe along with examples of practices adopted from other subspecialties, like pre-incisional antibiotics.
• 24:11
  SPEAKER_00: I don't know that there's an RCT that shows every requirement for every sterile implant or hand hygiene, which, you know, there's an awful lot of data, but I don't know that it's in every single piece.
• 24:21
  SPEAKER_00: And then devising a timeline for more gradual change can help people get to a place of best practice.
• 24:27
  SPEAKER_01: Thanks, Josh.
• 24:28
  SPEAKER_01: So lastly, the compendium recommends providing SSI rate feedback to surgical personnel and leadership.
• 24:35
  SPEAKER_01: So, Josh, I'm actually going to get your input here first.
• 24:38
  SPEAKER_01: We know that providing useful feedback is essential for any process to be successful.
• 24:43
  SPEAKER_01: So, do you have suggestions on how to best provide feedback?
• 24:46
  SPEAKER_00: Yes.
• 24:47
  SPEAKER_00: So, as you say, audit and feedback has been shown to be effective in numerous contexts.
• 24:51
  SPEAKER_00: Sharing both process and outcome data is important for preventing HAIs and SSI, and both of those are part of our expected, recommended, essential activities.
• 25:02
  SPEAKER_00: So there are two pieces that I want to touch on.
• 25:04
  SPEAKER_00: The first is the measures that you're sharing.
• 25:07
  SPEAKER_00: So choosing what to share is important.
• 25:10
  SPEAKER_00: The process data, like bundle adherence or successful execution of a practice, should be something that's readily measured.
• 25:17
  SPEAKER_00: So it doesn't require person time of observation or paper collation.
• 25:21
  SPEAKER_00: Ideally, it's electronic through the EMR.
• 25:24
  SPEAKER_00: That way you can turn it around quickly and you can allocate the resources that you would otherwise use to observe to other more productive things.
• 25:31
  SPEAKER_00: And the data that you share should be actions that can be influenced directly by those functioning or operating in the system.
• 25:39
  SPEAKER_00: For example, we know that underlying chronic disease is a significant risk factor for SSI, but we also know that a pre-op nurse can do nothing about that.
• 25:48
  SPEAKER_00: But what they can do is something about decolonization or something else or glucose, making sure that you're checking the glucose.
• 25:55
  SPEAKER_00: And so measuring those to help them see the productivity and whether or not they're contributing is very helpful.
• 26:03
  SPEAKER_00: The second thing is to think about your target audience.
• 26:06
  SPEAKER_00: So for whom is the feedback intended?
• 26:09
  SPEAKER_00: Oftentimes the focus might be on the surgeon rather than on others in the system or the system itself in their feedback and then their expectations.
• 26:35
  SPEAKER_00: And you're relieving non-surgeons of their SSI prevention responsibilities.
• 26:40
  SPEAKER_00: And so the feedback should be targeted to all of those involved in SSI prevention.
• 26:45
  SPEAKER_00: We talk about risk factors to mitigate preop intra, postoperative risk, which involves a lot of people who likely don't interact directly with each other.
• 26:54
  SPEAKER_00: The surgeon is a key component of the system, but it's not the only one.
• 26:58
  SPEAKER_00: And if you take, for example, preoperative antibiotics, there's someone who needs to identify the medication is needed, determine which one is appropriate, order the medication, prepare the medication in time to deliver before the incision, time the delivery properly, and document both the dose and the incision to ensure adherence.
• 27:18
  SPEAKER_00: To expect a surgeon to do that is unreasonable.
• 27:21
  SPEAKER_00: And so in a large system, there are going to be a lot of different people who do it.
• 27:25
  SPEAKER_00: An additional approach that we list in the chapter is observe and review practices in the preoperative clinic, post-anesthesia care unit, surgical intensive care unit, and surgical ward.
• 27:36
  SPEAKER_00: So again, think about how to include all of those involved in those work areas, including everybody who's involved in the perioperative world.
• 27:44
  SPEAKER_00: Outcome data is important, but may not be as impactful as process data to drive improvement.
• 27:50
  SPEAKER_00: Think about an SSI.
• 27:51
  SPEAKER_00: It may not occur for three months after a pre-op clinic visit, by which time the pre-op clinic providers may not remember the patient or their encounter, and any opportunities to improve at that moment is lost.
• 28:04
  SPEAKER_00: So what I would say is that think about the audience you're trying to reach and make the information useful to them in hand.
• 28:13
  SPEAKER_00: Don't just give outcome data.
• 28:15
  SPEAKER_00: And then finally, if you schedule yourself to share at regular intervals, that can be anticipated.
• 28:22
  SPEAKER_00: They can be delivered to existing or newly scheduled meetings where discussions can take place and then making the data easily accessible online because you're talking about three shifts of perioperative staff, you're talking about people who don't work nine to five.
• 28:36
  SPEAKER_00: All of that can foster a shared responsibility and a sense of teamwork.
• 28:40
  SPEAKER_00: You think about, as Patch described, this interdisciplinary team that gets together to talk about what are our challenges to achieving the glucose control and what do we need to do and how do we need to support it?
• 28:53
  SPEAKER_00: It's the same idea, just trying to foster it overall for SSI prevention.
• 28:57
  SPEAKER_01: Thanks, Josh.
• 28:58
  SPEAKER_01: Those are really important points, especially highlighting the interdisciplinary team.
• 29:02
  SPEAKER_01: So, Patch, what are your thoughts on this?
• 29:05
  SPEAKER_01: Do you have recommendations on practices that should be either used or avoided specifically for providing SSI feedback?
• 29:11
  SPEAKER_02: Well, I think Josh really put this in a in a very good perspective.
• 29:16
  SPEAKER_02: And I would just I'll describe one thing that uh we did at the University of Washington that I think is consistent with what Josh was telling us.
• 29:26
  SPEAKER_02: We looked at the concept of the potentially preventable surgical site infection, a concept that was uh published by Jim Lee uh from the Minnesota VA system uh many years ago.
• 29:39
  SPEAKER_02: And basically, what you do when the infection preventionist finds a surgical site infection, you look at it and you see, did we provide all of the preventive elements that we think should be done?
• 29:53
  SPEAKER_02: And if they were all provided the right dose, the right time, and the glucose control and so on, then it's an apparently unpreventable surgical site infection.
• 30:04
  SPEAKER_02: But if one of those was missed, it's a potentially preventable infection.
• 30:08
  SPEAKER_02: Uh so what we did at the UW was we formed a subcommittee of the hospital infection control committee called the Surgical Infection Prevention Committee.
• 30:20
  SPEAKER_02: And we asked our infection preventionist to identify surgical site infections, and we began by saying, okay, any infection you find, look and see whether the right antibiotic was given in the right dose at the right time and repeated for long operations.
• 30:40
  SPEAKER_02: If one of those things is missing, it's potentially preventable.
• 30:43
  SPEAKER_02: And then that data would be fed back to the surgical infection prevention committee, which had on it surgeons, anesthesiologists, nurses, surgeons from multiple specialties, pharmacists, and people working in the area of equipment sterilization.
• 31:01
  SPEAKER_02: And when we started that, 40% of all SSIs found were potentially preventable.
• 31:06
  SPEAKER_02: And we got that rate very low.
• 31:09
  SPEAKER_02: Then we said, okay, next, if the patient gets to recovery room cold, that's potentially preventable.
• 31:16
  SPEAKER_02: And our potentially preventable rate went up again.
• 31:19
  SPEAKER_02: And then we said, after that was done, we said, okay, if the patient reaches recovery room hyperglycemic, that's potentially preventable.
• 31:28
  SPEAKER_02: And a graph of our potentially preventable infections went up and down and up and down as we gradually increased the definition, but our overall infection rate slowly and gradually dropped during that time period.
• 31:43
  SPEAKER_02: And um we published that in surgical uh infections uh in 2021 with our infection preventionist as the lead author.
• 31:52
  SPEAKER_01: Thanks, Patch.
• 31:53
  SPEAKER_01: I like that iterative approach.
• 31:55
  SPEAKER_00: That's fantastic, Patch.
• 31:57
  SPEAKER_00: Can I just add so two quick things?
• 31:58
  SPEAKER_00: One is I love that each time once you achieve the goal, you set another one, right?
• 32:04
  SPEAKER_00: Because nobody has zero SSIs.
• 32:06
  SPEAKER_00: We don't know all the risk factors, but we can sure as heck make sure that we're trying to control every single one that we know of, because that will prevent as many SSIs as we can.
• 32:16
  SPEAKER_00: The process that you have of of going through and looking at all the things, some folks call that an apparent cause analysis or an ACA.
• 32:24
  SPEAKER_00: And just for listeners, I would Google that because there are lots of forms and lots of formats that are easily accessible that you can utilize to do that.
• 32:32
  SPEAKER_00: And then the last is that I love that the overall infection rate went down slowly.
• 32:37
  SPEAKER_00: It takes time to see an effect on the outcome in SSI.
• 32:41
  SPEAKER_00: SSI is a tough one because it takes so long, but slow and steady wins the race.
• 32:46
  SPEAKER_02: I do know how to have zero surgical site infections.
• 32:50
  SPEAKER_02: Don't operate.
• 32:52
  SPEAKER_02: Uh-huh.
• 32:52
  SPEAKER_01: Well, Michael, I'll give you the last word here.
• 32:54
  SPEAKER_01: Anything else to add?
• 32:56
  SPEAKER_03: So this has been a great conversation.
• 32:58
  SPEAKER_03: I really appreciate the uh examples that have been given, and it really does take a village.
• 33:04
  SPEAKER_03: It takes a large multidisciplinary group across the healthcare uh system to really think about everyone's role and responsibility.
• 33:12
  SPEAKER_03: I get jotted down a few notes that I was going to make at the end, and and you know, Josh and Patch have have made some of them in their concluding remarks as well.
• 33:19
  SPEAKER_03: You know I think it's important that you know the validity of the data that you are looking at.
• 33:26
  SPEAKER_03: We collect a lot of data, but you need to know how it's being collected, how up to date it is relative to the current state.
• 33:34
  SPEAKER_03: And it's also important that you include the group whose performance is being evaluated from the beginning.
• 33:40
  SPEAKER_03: Because what you don't want to end up doing is finding about the validity and risk adjustment of the data on the back end.
• 33:47
  SPEAKER_03: You really want to have that partnership from the get-go.
• 33:50
  SPEAKER_03: It's also important not to oversell the trend.
• 33:52
  SPEAKER_03: You know, we just made that point that this is iterative, it slowly improves, there are going to be peaks and valleys, but you want to kind of keep moving towards better.
• 34:00
  SPEAKER_03: And so I often kind of say to folks, you know, one dot is a point, two dots are a line, three dots may be a trend, but maybe not.
• 34:07
  SPEAKER_03: And you want to kind of think about what's happening longitudinally.
• 34:11
  SPEAKER_03: It's also in that realm important to understand noise versus true quality improvement.
• 34:16
  SPEAKER_03: And so there are many hospitals that are best one year and worse the next.
• 34:22
  SPEAKER_03: What you're really looking for is sustained improvement.
• 34:25
  SPEAKER_03: You want to be able to link what has changed and how it was sustained in order to drive that change.
• 34:30
  SPEAKER_03: You don't want to just kind of say, yay, we we won.
• 34:33
  SPEAKER_03: You want to actually be able to tell a story.
• 34:34
  SPEAKER_03: This is how we did it, and this is how we're going to continue doing it.
• 34:37
  SPEAKER_03: And the final thing, you know, on that as we think about data, is eventually we need to stop collecting more data.
• 34:45
  SPEAKER_03: We have to select a lever, pull that lever, demonstrate the change, and if the change has occurred, lock in that change and then select another target.
• 34:53
  SPEAKER_03: You can get stuck in this data paralysis, um, and you really need to think about change management and moving forward.
• 35:00
  SPEAKER_01: Well, thank you all for such a fantastic conversation.
• 35:03
  SPEAKER_01: We appreciate you joining us today.
• 35:05
  SPEAKER_00: Thanks very much.
• 35:06
  SPEAKER_00: This was a lot of fun nerding out on SSI prevention.
• 35:09
  SPEAKER_00: Thank you, Michael and Patch and Jess.
• 35:11
  SPEAKER_00: Thank you.
• 35:11
  SPEAKER_00: This has been a wonderful conversation.
• 35:13
  SPEAKER_02: I really enjoyed it, and I think this is a great example of multidisciplinary approach to a difficult problem.
• 35:20
  SPEAKER_01: Thank you all.
• 35:21
  SPEAKER_01: You can find more educational content like this podcast on Shay's Online Education Center, Learning CE, at www.learningce.shay hyphenonline.org.
• 35:32
  SPEAKER_01: This concludes today's episode of the updates from the SSI Compendium series.
• 35:37
  SPEAKER_01: Thank you for tuning in.