Centers for disease control and prevention guideline for the prevention of surgical site infection, 2017

IMPORTANCE: The human and financial costs of treating surgical site infections (SSIs) are increasing. The number of surgical procedures performed in the United States continues to rise, and surgical patients are initially seen with increasingly complex comorbidities. It is estimated that approximately half of SSIs are deemed preventable using evidence-based strategies. OBJECTIVE: To provide new and updated evidence-based recommendations for the prevention of SSI. EVIDENCE REVIEW: A targeted systematic review of the literature was conducted in MEDLINE, EMBASE, CINAHL, and the Cochrane Library from 1998 through April 2014. A modified Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach was used to assess the quality of evidence and the strength of the resulting recommendation and to provide explicit links between them. Of 5759 titles and abstracts screened, 896 underwent full-text review by 2 independent reviewers. After exclusions, 170 studies were extracted into evidence tables, appraised, and synthesized. FINDINGS: Before surgery, patients should shower or bathe (full body) with soap (antimicrobial or nonantimicrobial) or an antiseptic agent on at least the night before the operative day. Antimicrobial prophylaxis should be administered only when indicated based on published clinical practice guidelines and timed such that a bactericidal concentration of the agents is established in the serum and tissues when the incision is made. In cesarean section procedures, antimicrobial prophylaxis should be administered before skin incision. Skin preparation in the operating room should be performed using an alcohol-based agent unless contraindicated. For clean and clean-contaminated procedures, additional prophylactic antimicrobial agent doses should not be administered after the surgical incision is closed in the operating room, even in the presence of a drain. Topical antimicrobial agents should not be applied to the surgical incision. During surgery, glycemic control should be implemented using blood glucose target levels less than 200 mg/dL, and normothermia should be maintained in all patients. Increased fraction of inspired oxygen should be administered during surgery and after extubation in the immediate postoperative period for patients with normal pulmonary function undergoing general anesthesia with endotracheal intubation. Transfusion of blood products should not be withheld from surgical patients as a means to prevent SSI. CONCLUSIONS AND RELEVANCE: This guideline is intended to provide new and updated evidence-based recommendations for the prevention of SSI and should be incorporated into comprehensive surgical quality improvement programs to improve patient safety.

Process of care and outcomes for elderly patients hospitalized with peptic ulcer disease: results from a quality improvement project.

CONTEXT: Since publication in 1994 of guidelines for management of peptic ulcer disease (PUD), trends in physician practice and outcomes related to guideline application have not been evaluated. OBJECTIVES: To describe changes in process of care that occurred in a quality improvement program for patients hospitalized with PUD and to evaluate associations between in-hospital treatment of PUD and 1-year rehospitalization for PUD and mortality in a subset of these patients. DESIGN, SETTING, AND PATIENTS: Cohort study of 4292 sequential Medicare beneficiaries hospitalized at acute care hospitals with a principal diagnosis of PUD in 5 states (Colorado, Georgia, Connecticut, Oklahoma, and Virginia) in 1995 (baseline) and 1997 (remeasurement); outcomes were evaluated for 752 patients in Colorado. MAIN OUTCOME MEASURES: Changes in rates of screening for Helicobacter pylori infection, treatment for H pylori infection, screening for nonsteroidal anti-inflammatory drug (NSAID) use, counseling about NSAID use; outcomes included rehospitalization for PUD and all-cause mortality within 1 year of discharge in Colorado. RESULTS: Screening for H pylori infection increased significantly (12%-19% increase; P<.001) in each of the 5 states. Treatment of H pylori infection increased in each state and was significantly increased for the entire group of hospitalizations examined (8% increase overall; P =.001). Despite increased screening, detection of H pylori infection was less frequent than expected in every state, (13%-24%) and did not increase in any state. Screening for and counseling about NSAIDs did not significantly increase overall or in any state. In the Colorado cohort, the proportion of patients rehospitalized was unchanged in 1995 (8.9%) and 1997 (6.8%), and 124 patients (16%) in the combined 1995 and 1997 cohorts died within 1 year. Treatment for H pylori was not associated with a reduction in rehospitalization within 1 year (adjusted odds ratio [OR], 1.24; 95% confidence interval [CI], 0.65-2.36) or with a reduction in mortality (adjusted OR, 1.08; 95% CI, 0.68-1.71). Counseling about NSAID use was associated with a decrease in risk of 1-year rehospitalization for PUD (adjusted OR, 0.47; 95% CI, 0.22-0.99) and risk of all-cause mortality (adjusted OR, 0.44; 95% CI, 0.26-0.75). CONCLUSIONS: This quality improvement program for elderly patients with PUD resulted in increased screening for H pylori and increased treatment of H pylori infection but no change in counseling about NSAID use. However, with the low prevalence of H pylori detected, treatment of H pylori infection was not associated with a reduction in repeat hospitalization for PUD or subsequent mortality, whereas counseling about the risks of using NSAIDs was associated with a reduction in the risk of both outcomes.

Care of acute myocardial infarction in Oklahoma: an update from the Cooperative Cardiovascular Project.

Acute myocardial infarction remains a common cause of morbidity and mortality in Oklahoma. Nearly 6,000 Oklahoma Medicare beneficiaries are admitted to the hospital with an acute myocardial infarction each year. The death rate from coronary heart disease in Oklahoma is one of the highest in the nation. Utilizing structured medical record review, we have evaluated care given to 6,104 Medicare beneficiaries with acute myocardial infarction in 1994, 1996, and 1998. Since 1994, there have been significant improvements in the use of aspirin and beta-blockers at discharge, and avoidance of calcium channel blockers in those patients with poor left ventricular function. Documentation of smoking cessation counseling decreased significantly from 1994 to 1998. Other measures of quality of care did not change significantly. Despite better performance on many of the measures of quality, we should not be too complacent about the results, as there continues to be considerable room for improvement in care.

Comparison of an enhanced versus a written feedback model on the management of Medicare inpatients with venous thrombosis.

BACKGROUND: A multistate randomized study conducted under the Health Care Financing Administration's (HCFA's) Health Care Quality Improvement Program (HCQIP) offered the opportunity to compare the effect of a written feedback intervention (WFI) with that of an enhanced feedback intervention (EFI) on improving the anticoagulant management of Medicare beneficiaries who present to the hospital with venous thromboembolic disease. METHODS: Twenty-nine hospitals in five states were randomly assigned to receive written hospital-specific feedback (WFI) of feedback enhanced by the participation of a trained physician, quality improvement tools, and an Anticoagulant Management of Venous Thrombosis (AMVT) project liaison (EFI). Differences in the performance of five quality indicators between baseline and remeasurement were assessed. Quality managers were interviewed to determine perceptions of project implementation. RESULTS: No significant differences in the change from baseline to remeasurement were found between the two intervention groups. Significant improvement in one indicator and significant decline in two indicators were found for one or both groups. Yet 59% of all quality managers perceived the AMVT project as being successful to very successful, and more EFI quality managers perceived success than did WFI managers (71% versus 40%). In the majority of EFI hospitals, physician liaisons played an important role in project implementation. CONCLUSION: Study results indicated that the addition of a physician liaison, quality improvement tools, and a project liaison did not provide incremental value to hospital-specific feedback for improving quality of care. Future studies with larger sample sizes, lengthier follow-up periods, and interventions that include more of the elements shown to affect practice behavior change are needed to identify an optimal feedback model for use by external quality management organizations.

Multistate utilization, processes, and outcomes of carotid endarterectomy.

OBJECTIVES: The purpose of this study was to describe variation in utilization, care processes, and outcomes for carotid endarterectomy (CEA) procedures in 10 states. METHODS: We reviewed the medical records of Medicare patients who underwent 10,561 CEA procedures between June 1, 1995, and May 31, 1996, in 10 different states to determine indications, care processes, and outcomes. This study also included medical record review of hospital readmissions within 30 days of the procedure and identification of out-of-hospital deaths from the Medicare beneficiary files. RESULTS: Utilization rates of CEA varied from 25.7 to 38.4 procedures per 10,000 Medicare beneficiaries among states. The overall combined event rate (30-day stroke or mortality) was 5.2% for primary CEA alone (n = 9945). The mortality rate was 1.5%, and the nonfatal stroke rate was 3.7%. Combined event rates (CEA alone) by surgical indication were 7.7% for stroke (n = 1037), 7.4% for transient ischemic attack (n = 1304), 5.3% for nonspecific symptoms (n = 3713), and 3.7% for asymptomatic patients (n = 3891). The combined event rates (CEA alone) among states ranged from 4.1% to 7.7% with the event rates in asymptomatic patients ranging from 2.3% to 6.7%. In a multivariate analysis (correcting for indication), the use of preoperative antiplatelet agents (odds ratio [OR], 0.70), intraoperative heparin (OR, 0.49), and patch angioplasty (OR, 0.73) was significantly associated with lower combined event rates. There were significant differences among states in the use of preoperative antiplatelet therapy (range, 56%-70%) and patch angioplasty (range, 11%-49%). Combined event rates for repeat procedures (n = 380) and CEA combined with coronary artery bypass grafting (n = 236) were 6.3% and 17.4%, respectively. CONCLUSIONS: The striking variation among states suggests that there is room for improvement in the utilization, care processes, and outcomes of CEA. All surgeons performing CEA should participate in outcome assessment and adopt protocols that include the routine administration of antiplatelet agents preoperatively, the use of heparin intraoperatively, and patch angioplasty of the endarterectomy site.

Variations among hospitals in the quality of care for heart failure.

CONTEXT: Determining variations in quality of care among hospitals can help direct attention to poorly performing institutions. PRACTICE PATTERN EXAMINED: The proportion of patients with congestive heart failure meeting various quality criteria in 69 hospitals. HOSPITAL SELECTION: The hospitals were voluntary participants in a quality improvement program in five states (Colorado, Connecticut, Georgia, Oklahoma, and Virginia). PATIENT SELECTION: All patients with congestive heart failure discharged from the participating hospitals during a 15-month period in 1995 to 1996 (or, for hospitals with more than 50 eligible patients, a random sample of 50 patients). The total sample consisted of 2077 patients. DATA SOURCE: Documentation in the hospital medical record of left ventricular function, discharge medications, and discharge instructions. RESULTS: Left ventricular function was determined in 72% of patients (range across hospitals, 18% to 97%). Among patients with left ventricular systolic dysfunction, 79% were prescribed an angiotensin-converting enzyme inhibitor (range, 54% to 94%). Only 23% of the patients prescribed angiotensin-converting enzyme inhibitors received the target dose (range, 0% to 60%). Sixty-four percent of patients were counseled about the importance of a low-sodium diet at discharge (range, 25% to 97%), but only 8% were counseled about daily weight monitoring (range, 0% to 30%). CONCLUSION: Our results show substantial hospital-to-hospital variation in the quality of care for patients with heart failure.

The quality of care for Medicare patients with peptic ulcer disease.

OBJECTIVE: The aim of this study was to examine quality of care for hospitalized Medicare beneficiaries with peptic ulcer disease. METHODS: Collaborating with five Peer Review Organizations, we used 1995 Medicare claim files to select samples of inpatients with a principal diagnosis of peptic ulcer disease. Quality of care indicators developed by content experts included percentages for ulcer patients tested for Helicobacter pylori (H. pylori); biopsied patients who received tissue tests; H. pylori-positive patients who received appropriate therapy; and ulcer patients screened for preadmission nonsteroidal anti-inflammatory drug (NSAID) use and counseled about risks. RESULTS: Of 2,644 patients eligible for medical record review, 56% were tested for H. pylori, and 73% of those testing positive were treated appropriately; 84% of patients with endoscopic biopsies received a tissue test for H. pylori; 74% of patients were screened for preadmission NSAID use, 24% had documented counseling of NSAID use, and only 2% had documented counseling on the ulcer risk of NSAID use. Statistically significant regional variation occurred in four of six quality indicators. Outpatient records were reviewed for 529 patients to document prior outpatient H. pylori in this population; only 2% (n = 12) were tested for H. pylori in the year before admission. CONCLUSIONS: Opportunities exist to improve quality of care by testing for and treating H. pylori in hospitalized Medicare beneficiaries with peptic ulcer disease and to improve screening for NSAIDs and counseling on ulcer risks.

Comparison of influenza immunization rates for Oklahoma Medicare patients: 1995, 1996 and 1997.

The Health Care Financing Administration has reported influenza immunization rates since 1994. The Department of Health and Human Services has set a minimum national target rate for the annual immunization of the elderly population at 60 percent, as published in Healthy People 2000. The Oklahoma Foundation for Medical Quality analyzed the Medicare claims data for Oklahoma for the 1995, 1996, and 1997 influenza seasons. Additionally, we reviewed the Behavioral Risk Factor Surveillance System influenza immunization data for 1995. Claims data for the 1997 influenza season show the immunization rate for the Medicare population of Oklahoma is 41.4 percent. The immunization rate for the African-American Medicare population was 22.3 percent for 1997, compared with 42.2 percent for the Caucasian population. The ten most populous counties in the state had a 9-percent higher rate of immunization than the other 67 counties. The Medicare population in Oklahoma is not receiving the influenza vaccination at the target rate. Especially underserved are the African-American and non-urban populations. There appear to be opportunities for improvement in the provision of the influenza vaccination for the Medicare population of Oklahoma.

Underuse of venous thromboembolism prophylaxis for general surgery patients: physician practices in the community hospital setting.

BACKGROUND: Venous thromboembolism is a common complication of surgery. Although surveys of physician self-reported practices have suggested near universal support for routine use of measures to prevent venous thromboembolism, medical record auditing has demonstrated underuse. OBJECTIVE: To assess physician practices of venous thromboembolism prophylaxis in the community hospital setting. METHODS: Retrospective review of the medical records from 20 hospitals in Oklahoma of 419 Medicare patients aged 65 years or older undergoing major abdominothoracic surgery between April 1 and December 31, 1995. Utilization rates of prophylaxis stratified according to patient risk for venous thromboembolism were measured. RESULTS: Prophylaxis measures were implemented for only 160 (38%) of 419 patients studied (95% confidence interval, 33%-43%). There was little variation in the use of prophylaxis based on the risk for venous thromboembolism. Only 97 (39%) of 250 patients (95% confidence interval, 33%-45%) at very high risk received any form of prophylaxis and of these 97, only 64 patients (66%) received appropriate measures (95% confidence interval, 56%-75%). CONCLUSIONS: Despite widely disseminated, evidence-based recommendations, venous thromboembolism prophylaxis is underused in Medicare patients undergoing major abdominothoracic surgery in community hospitals in Oklahoma.

Characteristics and hospital utilization of the Oklahoma Medicare population: 1994-1996.

BACKGROUND AND OBJECTIVES: Epidemiologic surveillance reports that focus on hospital utilization are limited in number. The objective of this study was to provide a current profile of the demographic characteristics of the Oklahoma Medicare population and to profile trends in hospital utilization. METHODS: Using the Medicare enrollment files and discharge claims data sets for 1994 through 1996, demographic characteristics and surveillance measures were calculated for enrollees based on age, sex, race/ethnicity, principal diagnosis, and primary procedure. In addition, average hospital charge and average reimbursement were evaluated by diagnosis-related group. RESULTS: The Oklahoma Medicare population has grown by 2.5% from 1994 through 1996. The majority (87.5%) of the enrollees are aged 65 or greater. Of those less than 65 years of age, most are enrolled in the program because of disability. Less than 5% of the Medicare population was enrolled in a managed care plan during 1996. The overall length of stay, in-hospital mortality, and 30-day mortality rates have declined for all age groups and principal diagnoses profiled. More than one fifth of all of the Medicare discharge claims were related to heart disease. CONCLUSIONS: The Medicare discharge claims files represent a useful source of data from which to conduct surveillance on this population. The declining rates of mortality and length of stay that were demonstrated for all Medicare age groups must be taken into account in any evaluation of health care services that seeks to address the impact of quality improvement or utilization management strategies over time.

Assessing HCFA's Health Care Quality Improvement Program.

BACKGROUND: In 1992 the Health Care Financing Administration introduced the Health Care Quality Improvement Program (HCQIP), through which quality improvement projects are conducted in partnership with quality improvement organizations (QIOs), hospitals, health plans, or physicians. An evaluation of HCQIP began in May 1996 in response to the QIOs' request for an independent assessment of their activities. METHODOLOGY: The methodology and objectives of the evaluation were determined by an independent panel. The QIOs' full cohort of 970 HQIP projects could not be reviewed in the 10-month time frame available, but two topics were chosen: the management of warfarin or aspirin in patients with atrial fibrillation and the management of community-acquired pneumonia. FINDINGS: Analyses were limited to the 49 of the 68 projects that had progressed to the "improvement plan implemented" stage. However, only 39 of these 49 projects had information on outcomes, organization changes, and/or changes in process of care--and only 20 of the 49 had moved beyond the "improvement plan implemented" phase. Feedback of data led hospitals collaborating on improvement projects to revise or create processes of care. DISCUSSION: Although the assessment is the most comprehensive of its type to date, it should be viewed as a pilot study of some of the methods that could be incorporated in a more extensive and rigorous future evaluation of the impact of the HCQIP projects. Specific recommendations include random sampling of HCQIP projects across all clinical areas, conducting both prospective and retrospective assessments, developing uniform process and outcome program impact measures, and developing sustainable, ongoing automated data abstraction and analysis systems.

The Cooperative Cardiovascular Project in Oklahoma.

BACKGROUND AND OBJECTIVES: Acute myocardial infarction is the leading cause of death in the United States and a common cause for admission of Oklahoma Medicare beneficiaries. Based on guidelines for the management of acute myocardial infarction published by a joint committee of the American College of Cardiology and the American Heart Association, the Cooperative Cardiovascular Project was developed by the Health Care Financing Administration to measure performance on quality indicators that describe care provided to Medicare beneficiaries. The objective of the project is to use those performance measures to assist hospitals in the development of quality improvement efforts for acute myocardial infarction care. METHODS: Retrospective review was performed on the inpatient medical records of 3,436 patients from 102 hospitals in Oklahoma and a random national sample of 2,441 patients discharged with a principal diagnosis of acute myocardial infarction. RESULTS: The diagnosis of acute myocardial infarction was confirmed in 3,055 (89%) of the cases reviewed. For patients considered to be ideal candidates for an intervention, 62% received reperfusion therapy (thrombolytic or PTCA), 84% received aspirin during the hospitalization, 76% received aspirin at discharge, and 40% received beta-blockers at discharge. There were significant variations in performance between hospital peer groups in the use of reperfusion therapy, aspirin, beta-blockers, and smoking cessation counseling. CONCLUSIONS: Potentially life-saving treatments for Medicare patients hospitalized with an acute myocardial infarction are often underutilized. Improving quality of care for Medicare beneficiaries with acute myocardial infarction has been identified as a national priority.

Carotid endarterectomy in Oklahoma Medicare beneficiaries: patient characteristics and outcomes.

BACKGROUND AND OBJECTIVES: Ischemic stroke represents the third leading cause of death and the most common cause of permanent disability in the United States. Carotid endarterectomy has been widely utilized as a procedure to reduce the risk of stroke and represents the most commonly performed peripheral arterial surgery. This cooperative project was initiated to assess the appropriateness of carotid endarterectomies performed on Medicare beneficiaries and the postoperative outcomes (mortality and stroke) in these patients. METHODS: Retrospective review was performed on the inpatient medical records of 774 patients who underwent 813 carotid endarterectomy procedures in eight hospitals during calendar years 1993 and 1994. Medicare claims data were also analyzed for all carotid endarterectomies performed in Oklahoma during calendar years 1992 through 1995. RESULTS: A history of transient ischemic attack or stroke in the distribution of the operated carotid artery was documented in 57% of the cases. The majority of patients had preoperative ultrasound imaging of the carotid arteries and a preoperative angiogram was performed before 96% of the procedures. Accepted indications for the surgery were documented for 98% of the procedures. Stroke or death within 30 days of the date of the carotid endarterectomy occurred after 4.9% (0-8.8% by hospital) of the procedures. CONCLUSIONS: This project demonstrated considerable variation between hospitals in the outcomes of patients undergoing carotid endarterectomy and the potential for improved care of patients with regard to discharge planning, education, and use of anticoagulant or antiplatelet medications postoperatively.

Community-acquired pneumonia in Oklahoma: characteristics and management of hospitalized Medicare beneficiaries.

The Oklahoma Foundation for Medical Quality initiated a cooperative project to evaluate the management of community-acquired pneumonia in Oklahoma Medicare beneficiaries. We reviewed the medical records of 767 patients discharged with a principal diagnosis of pneumonia during fiscal year 1993 from 20 hospitals. Of the 757 cases that met criteria for analysis, 92 (12%) died during hospitalization. There were significant differences between patients who survived and those who died with respect to patient age, admission source, and absence of indicators of severe pneumonia. Deviations from the American Thoracic Society guidelines for the treatment of community-acquired pneumonia were demonstrated with regards to the collection of routine sputum gram stains and cultures, blood cultures, and thoracentesis. We also demonstrated variations between hospitals in the timing of the first dose of antibiotic administered after admission of the patient. Based on this project, there appear to be opportunities for improvement in the care provided to patients admitted to the hospital with pneumonia.