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Today’s Webinar will begin at noon
3/27/12
Welcome from Barb DeBaun, RN, MSN, CIC
Introduction
Introduction
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Heather Young, MD
Surgical Site Infection after Hysterectomy in Colorado
•Heather Young MD•March 27, 2012
WHYWHY
WHAT
HOW
Objectives
• WHY– Public reporting in CA, CO and nationwide– Our SSI problem
• WHAT– Pilot and statewide study
• HOW– Transfusion and outcomes– Transfusion and immunity– Transfusion at our hospital
Why we started this project
WHYWHY
WHAT
HOW
Public Reporting of HAI
Committee to Reduce Infection Deaths 2010
StateState
CMSCMS
>=<
>=<
Pay for performanceOnline hospital comparisons
Public Reporting Agencies
NHSN
NHSN
All orthopedic, cardiac, and GI surgeries including:
Hip prosthesisKnee prosthesisOpen fracture fixationLaminectomySpinal fusionSpinal refusion
Coronary bypass graftingCardiac surgeryPacemaker surgery
Colon surgeryRectal surgerySmall bowel surgeryGallbladder surgeryAppendectomyGastric surgeryBiliary, liver, pancreatic surgeries
Backer 2011
AUGUST 2007Coronary artery bypass graftingPartial & total knee replacementPartial & total hip replacement
AUGUST 2008Herniorrhaphy
AUGUST 2009Vaginal hysterectomy
Abdominal hysterectomy
Reese 2011
JANUARY 2012Colon surgeryBreast surgery
Why we started this project
WHY
WHAT
HOW
What we did and What we found
Preparation for Reporting
Jul-Dec 2006
Jan-Jun 2007
Jul-Dec 2007
Jan-Jun 2008
Jul-Dec 2008
Jan-Jun 2009
NationalRate
Why we started this project
WHY
WHAT
HOW
What we did and What we found
Pilot Data, Study Design
Single center, retrospective chart review
Inclusion:• All patients who had total abdominal hysterectomy (TAH)
• Dec 30, 2005, to Mar 9, 2010• Age ≥ 18 y.o.
Exclusion:• Emergent surgery• Surgery for known infection (tubo-ovarian abscess)
• No follow-up documented in 30 days after TAH
Young 2011
Hypotheses
• Do our surgeons adhere to evidence-based guidelines?
• Are there other published variables that we should consider for intervention?
Study Population N (%)
Total number of patients
229 (100%)
Excluded from analysisEmergent indication
No TAH performedSurgery for TOA
No follow-up in 30 d after TAH
37 (16.2%)26542
Included in analysis
192 (83.8%)
Developed SSI 21 (10.9%)
Inclusion/Exclusion
Young 2011
Patient & Hospital Variables
PMHx, PSHx
Indication for TAH
Length of time in OR
Estimated blood loss (EBL)
Blood transfusion
Concomitant OR procedures
Type of skin incision
Surgeon
ASA score
Wound class
SCIP measures compliance
Olsen 2009; Ahmed 2001; Taylor 1998; Shapiro 1982; Meltomaa 2000; Molina-Cabrillana 2008; Ghezi 2009; Leung 2007; Persson 1996
Adherence to SSI Bundle
0
20
40
60
80
100
120
Perc
enta
ge
No SSI SSI
Antibiotics within 60 minutes of incision
Appropriate antibiotics
PACU arrival temperature ≥36 degrees
CompositeYoung 2011
Green = SSIBlue = No SSI
VariableSSI N, %
No SSI N, %
P
Diabetes 419.1%
1810.5% 0.247
Smoking 419.1%
5833.9% 0.169
ObesityBMI ≥ 30
1466.7%
7645.1% 0.061
Blood transfusio
n
628.6%
1810.5% 0.018
EBL ≥ 500 mL
1047.6%
4725.7% 0.035
Selected Variables and SSI
Young 2011
VariableSSI N, %
No SSI N, %
P
Diabetes 419.1%
1810.5% 0.247
Smoking 419.1%
5833.9% 0.169
ObesityBMI ≥ 30
1466.7%
7645.1% 0.061
Blood transfusio
n
628.6%
1810.5% 0.018
EBL ≥ 500 mL
1047.6%
4725.7% 0.035
Selected Variables and SSI
Young 2011
Laboratory Variables
Pre-operative creatinine
Pre-operative complete blood count
Post-operative hemoglobin / hematocrit
Microbiology, if applicable
Meltomaa 2000
Lab ValueSSI
Mean (SD)No SSI
Mean (SD)P
WBC 7.75 (2.66)7.65 (2.67)
0.869
Platelet 359 (133) 335 (137) 0.448
Hematocrit37.94 (4.10)
39.26 (4.87)
0.234
Post-operative hematocrit
31.81 (4.13)
31.67 (5.74)
0.913
Delta hematocrit
6.13 (4.06)7.62 (4.94)
0.187
Lab Values and SSI
Young 2011
Model I Model II
N = 192EBL <500
mLN = 138
EBL ≥500 mL
N = 54
Blood transfusio
n
3.581.21, 10.62
7.561.59, 35.98
1.140.25, 5.16
BMI ≥302.55
0.96, 6.74--- ---
Multivariate Analysis
Young 2011
Reasons for Blood Transfusion
Variable Frequency“Anemia” 72.7%
“High amount of EBL”
27.3%
“Dizziness” or “shortness of
breath”24.2%
“Comorbid heart disease”
18.2%
“Use of anticoagulants”
9.1%
Young 2011
Discussion
1.Obesity trends toward significance
2.Blood transfusion associated with SSI after TAH, especially if EBL <500 mL
1.Most indications for blood transfusion are subjective and potentially modifiable
Young 2011
Strengths & Weaknesses
Excellent post-discharge follow-up (99%)
Use of standard definitions
Single centerRelatively small number of infections and transfusions
Young 2011
Next Steps
• Expand to multicenter• State of Colorado• Survey of infection control nurses• IRB approved at 35 / 51 hospitals that perform TAH 8 still pending at publication 8 declined participation
• Colorado Hospitals Association (CHA)
Methods
• Survey designed• Website developed, supported by CHA
• Emails sent to all infection control nurses at participating facilities
• Stipend offered for participation
Young 2012
Participants
• 6 facilities• 567 subjects entered into database
• 20 excluded• 547 subjects analyzed
•10 (1.8%) developed SSI•35 (6.5%) had blood transfusion
Young 2012
Variable SSI No SSI P
BMI ≥30 60.0% 40.4% 0.33
Hct <30 0.0% 5.0% 1.00
EBL ≥500 mL 20.0% 6.7% 0.15
Blood transfusion
20.0% 6.2% 0.13
Antibiotic < 60 min before incision
100.0% 96.4% 1.00
Associations with SSI
Young 2012
Variable SSI No SSI P
BMI ≥30 60.0% 40.4% 0.33
Hct <30 0.0% 5.0% 1.00
EBL ≥500 mL 20.0% 6.7% 0.15
Blood transfusion
20.0% 6.2% 0.13
Antibiotic < 60 min before incision
100.0% 96.4% 1.00
Associations with SSI
Young 2012
OR to develop SSI95% Confidence Interval
EBL <500 mL EBL ≥500 mL
Blood transfusion
7.201.37, 37.72
---
Stratification Analyses
Young 2012
Discussion
• Blood transfusion and EBL ≥500 mL continue to be risk factors for SSI across several diverse institutions
• Biggest contribution of blood transfusion to SSI was in cases of EBL <500 mL
Young 2012
EBL 1200 mL
EBL 300 mL
pRBC pRBC
Who is more likely to have SSI?
How blood transfusions relate to patient outcomes
How blood transfusions relate to immune function
How we changed transfusions in hospital practice (sort of!)
WHY
WHAT
HOW
Transfusion-Related Immunomodulation (TRIM)
Vamvakas 2007
Beneficial effects Detrimental effects
↑ renal transplant survival
↓ Crohn’s disease flares
↓ miscarriage rate
↑ cancer recurrence
↑ post-operative bacterial infection
↑ mortality
TRIM and Hospital Outcomes
Blood transfusions are associated with worse
hospital outcomesEspecially in patients who are not severely ill or profoundly anemic
Hebert et al 1999
ICU Mortality– 838 patients, multicenter, Canada– Randomized controlled trial – Blood transfusion threshold of Hg 7-9
vs 10-12 in community ICU patients– Outcome: 30-day death
Hebert et al 1999
Received less blood
Received more blood
Hebert et al 1999
Received less blood
Received more blood
Hebert et al 1999
Received less blood
Received more blood
Rao et al 2004
Acute Coronary Syndrome– 24,112 patients, multicenter,
international– Observational study– Impact of blood transfusion in patients
with ACS– Outcome: 30-day death
Rao et al 2004
– 24,112 patients, international– Impact of blood transfusion on 30-day death in
patients with ACSNadir Hematocrit
20 25 30 35
Adjusted OR
(95% CI)
1.59 (0.95-2.66)
1.13 (0.70-1.82)
168.64 (7.49-3798)
291.64 (10.28-8274)
OR for 30-day death (by Hct)in patients w/ vs w/o blood transfusion
Rao et al 2004
– 24,112 patients, international– Impact of blood transfusion on 30-day death in
patients with ACSNadir Hematocrit
20 25 30 35
Adjusted OR
(95% CI)
1.59 (0.95-2.66)
1.13 (0.70-1.82)
168.64 (7.49-3798)
291.64 (10.28-8274)
OR for 30-day death (by Hct)in patients w/ vs w/o blood transfusion
Blood Transfusion & Surgical Site Infection
Author Year Surgical ProcedureMultivariate Analysis
Bernard 2009Visceral, vascular,
traumaOR 1.3
Rogers 2009Coronary artery
bypassOR 2.3
Poon 2009Laparoscopic colorectal
OR 2.4
Olsen 2008 Breast OR 3.4
Asensio 2008 Liver transplant OR 2.0
Blumetti 2007 Colorectal OR 2.3
Walz 2006Small bowel, colorectal
OR 1.6
Talbot 2004 Sternotomy OR 3.2
Olsen 2003Saphenous vein
harvestOR 2.8
Olsen 2009 Hysterectomy OR 2.4
Schwarzkopf 2010Thoracic, lumbar
spineOR 8.0
Costello 2010 Cardiac, pediatric OR 7.9
Tang 2001 Colorectal OR 5.3
Innerhofer 2005Hip and knee arthroplasty
OR 23.7
Koch et al 2008
Cardiac surgery– Newer vs older blood (<14 vs ≥14 days)– Outcomes: “serious adverse events” and
long term survival– Older blood associated with more serious
complications and deaths
Koch et al 2008
Death
VentilationRenal failureSepsis
Multiorgan failureLimb ischemiaComposite
Koch et al 2008NEWER BLOOD
OLDER BLOODSURV
IVAL
Offner et al 2002
Trauma surgery– Newer vs older blood (<14 vs ≥14 days)– Outcomes: “major infectious complications”– Older blood associated with more infections
Offner et al 2002
>14 Days
>21 Days
Mean # PRBC transfused
Yellow = no infectionBlue = major infection
Offner et al 2002
How does blood change the immune system?
Theory: Soluble factors in blood products accumulate over time and contribute to diminished immune
function.
Muylle et al 1993
Platelet study
Two phases:• (1) IL6, TNFα, IL1β at storage day 3, 5, 7• (2) Correlate IL6, TNFα, IL1β with febrile
transfusion reactions
Muylle et al 1993
(1) Cytokines at storage day 3, 5, 7• ↑IL6 in 8/12 samples at day 3• ↑IL6 in 10/12 samples at day 5, 7• ↑TNFα and IL1β in samples with ↑IL6• Linear increases with storage time• Increased cytokines about 100-1000x per-
storage levels
Similar findings found by Stack & Snyder 1994
Muylle et al 1993
(2) Correlate IL6, TNFα, IL1β with febrile transfusion reactions
• 45 platelet tx, 6 febrile reactions• ↑IL6 and TNFα in plasma of platelets that caused
reactions (p <0.001)
Muylle 1993
Conclusion: Perhaps some
transfusion reactions are due to transfusion of cytokine-rich plasma
Wadhwa et al 2000
Cytokine levels in WBC-reduced pRBC– Does the timing of WBC-reduction
influence cytokine levels over storage time?
– IL8, TGFβ1, RANTES
Wadhwa et al 2000
Conclusion:– Cytokines tend to increase over time in
stored blood products– Pre-storage plasma filtration prevents
cytokine accumulation compared to post-storage
Offner et al 2002
How does blood change the immune system?
Theory: Soluble factors in blood products accumulate over time and contribute to diminished immune
function
Muylle et al 1993
Platelet study
Two phases:• (1) IL6, TNFα, IL1β at storage day 3, 5, 7• (2) Correlate IL6, TNFα, IL1β with febrile
transfusion reactions
Muylle et al 1993
(1) Cytokines at storage day 3, 5, 7• ↑IL6 in 8/12 samples at day 3• ↑IL6 in 10/12 samples at day 5, 7• ↑TNFα and IL1β in samples with ↑IL6• Linear increases with storage time• Increased cytokines about 100-1000x per-
storage levels
Similar findings found by Stack & Snyder 1994
Muylle et al 1993
2) Correlate IL6, TNFα, IL1β with febrile transfusion reactions
• 45 platelet tx, 6 febrile reactions• ↑IL6 and TNFα in plasma of platelets that caused
reactions (p <0.001)
Muylle 1993
Conclusion: Perhaps some
transfusion reactions are due to transfusion of cytokine-rich plasma
Wadhwa et al 2000
Cytokine levels in WBC-reduced pRBC– Does the timing of WBC-reduction influence
cytokine levels over storage time? – IL8, TGFβ1, RANTES
Wadhwa et al 2000
Conclusion:– Cytokines tend to increase over time in
stored blood products– Pre-storage plasma filtration prevents
cytokine accumulation compared to post-storage
Summary
• Immune mediators are present and accumulate over time in blood products
Summary
• Immune mediators are present and accumulate over time in blood products
• The quantity of innate immune mediators in blood products is sufficient to cause febrile reactions to platelets
Summary
• Immune mediators are present and accumulate over time in blood products
• The quantity of innate immune mediators in blood products is sufficient to cause febrile reactions to platelets
• Levels of innate immune inhibitors in patients after receiving blood products have not been studied
Feedback, Follow-up
Jul-Dec 2006
Jan-Jun 2007
Jul-Dec 2007
Jan-Jun 2008
Jul-Dec 2008
Jul-Dec 2009
Jul-Dec 2010
Jan-Jun 2009
Jan-Jun 2010
Young 2011
Thank You
Notes will be on our website
Cynosure Quality Swap MeetMay 21, 2012
www.cynosurehealth.org
Thanks for joining us today