Speaker Disclosures 3M AMN Healthcare BESmith The Compass Group
1. Name the 2 most common mechanisms for wound contamination 2. Discuss 7 areas of opportunity for improvement 3. Describe the use of glycemic control and nasal decolonization initiatives for the reduction of SSIs. 4. List 3 ways to facilitate process improvements in the Operating Room
National Healthcare Safety Network (NHSN) 1999 HICPAC SSI Guidelines AORN Guidelines Surgical Care Improvement Project (SCIP) Measures
1. Antibiotic Prophylaxis Drug, Timing, Dosing 2. Hair Removal 3. Glycemic Control 4. Normothermia Expanded in June All surgical patients Qualitynet.org
Principles were developed to reduce the risk of wound contamination.
Defining the Risk of SSI Risk of SSI = Dose of Bacterial Contamination X Virulence Resistance of Host (patient) Berry & Kohns, Operating Room Technique, 11 th ed., p. 254
1. Exogenous sources Cleanliness of environment, lack of proper airflow, shedding by the Surgical Team 2. Endogenous sources Patients own skin/hair Infection at a remote site
People = Shedding ,000 particles per minute (Berry & Kohns, Operating Room Technique, 11 th ed., p. 252) Carried by wind currents to the sterile field which results in wound contamination. 1. Patient 2. Surgical Team 3. Ancillary Personnel 4. Sales Reps 5. Students 6. Passersby
Shedding plus Wind Currents Requires the control of: Amount of Traffic Traffic Patterns Sherertz, et al. Cloud HCWs. Emerging Infect Dis. 2001;7(2): Edmiston, et al. Airborne Particulates in the OR Environment. AORN 1999; 69(6):
Essential personnel only One foot (min) perimeter around sterile field Sterile fields should be a destination, not a thoroughfare Limit students and observers The right of the student to learn vs. the right of the patient to receive safe patient care DeKastle, R. Telesurgery: Providing Remote Surgical Observations for Students. AORN 2009; 90 (1): Utilize alternative methods of communication
1. Patient Pre-op Showers Hat and clean gown/linen for patient 2. Surgical Team Hand Hygiene Nocardia farcinica (Wenger, et al. J Infect Dis. Nov 1998) Proper aseptic technique Properly worn hats, masks, clean OR scrubs, jackets, minimal jewelry (AORN scrub attire)
Ban Skull Caps Dineen, P, Drusin, L. Epidemics of Postoperative Wound Infections Associated with Hair Carriers. Lancet 1973; (Nov)
Lack of Containment BAD VERY BAD
Standards of Excellence PETA APPROVED GOLD STANDARD
Room Requirements Ventilation System (15/hr – 3 fresh) Positive pressure Temperature (68-73° F) Humidity (30-60%) Room Cleaning Between cases Terminal cleaning Types of construction materials Clutter AORN, Recommended Practices for Perioperative Nursing: Safe Environment of Care. (2008 ed., p 357)
Requires strict adherence to the principles of aseptic technique by all team members for every patient on every case. ORs that value these principles create a patient centered culture. Girard, NJ. Surgical Conscience: Still Pertinent. AORN (2007):86 (1);
3. Sterilization Proper Management of Sterile Processing Departments Technology Workflow Staff certification Proper Sterilization Processes Focus area for The Joint Commission Cleaning, sterilization, and storage _sterilization.htm
Utilized for: Dropped instruments Poorly designed work processes Lack of instrumentation Surgeon scheduling Results in contamination due to: Poor cleaning due to lack of time Methods of delivery to the sterile field Closed containers are best practice TJC will be looking for them Carlo, A. The New Era of Flash Sterilization. AORN 2007: 86(1); p
Flash Data Calculation: # of flash events = rate x 100 # of cases/month
SCIP Measures INF 1,2,3 Goal >90% Best Practice- Anesthesiologists Proper dosage for obese population (BMI>30) Dont forget redosing q 3 hours
SCIP INF 6: Surgery patients with appropriate hair removal. Minimize as much as possible Clippers only Not in the OR!
The attributes of an appropriate surgical skin antiseptic require: The ability to significantly reduce microorganisms (2 log, 3 log) Provide broad spectrum activity Be fast acting Have a persistent effect All products with FDA approval meet this criteria AORN, Recommended Practices for Perioperative Nursing: Skin Antisepsis. (2008 ed., pp )
Other Skin Antisepsis Considerations 1. Procedure 2. Prep area 3. Application Methodology Scrubbing vs. Painting 4. Length of the procedure 5. Challenges to the prep area -blood, saline, friction 6. Patient Safety
Critical Thinking is Required Ultimately, the OR nurse decides at the point of care by assessing the patient to insure that the skin antisepsis planned for will be appropriate for that patient based on allergy status, body site, and skin integrity.
CDC SSI guideline states to use an appropriate antiseptic SHEA Compendium - Optimal preparation and disinfection of the operative site AORN compares products but does not provide specific product recommendations
Current Research Limited research is available that compares commonly used skin antiseptic agents with SSI outcomes The majority of the literature compares microbial counts The correlation between microbial counts and SSI outcomes is unclear
Current Research 1. Saltzman, MD, et al. Efficacy of Surgical Preparation Solutions in Shoulder Surgery. J Bone Joint Surg AM 2009;91: Microbial culture study of 150 patients Compared 3 methods Iodophor Scrub/Paint vs. ChloraPrep® vs. Duraprep Result Microbial counts were less using ChloraPrep® SSI Outcome was no SSIs in any of the groups
Current Research 2. Swenson, et al. Preoperative skin preparation on postoperative wound infection: a prospective study of three skin preparation protocols. Infect Control Hosp Epidemiol 2009; 30: SSI Outcome study of 3209 general surgery patients Compared 3 methods Iodophor Scrub/ETOH/Paint vs. ChloraPrep® vs. DuraPrep Result SSI Outcomes- A statistical difference with lower SSI rates using iodine based products.
Current Research 3. Darouiche, RO, et al. Chlorhexidine-Alcohol versus Povidone-Iodine for Surgical-Site Antisepsis. N Engl J Med 2010; 362(1): Microbial culture study of 849 patients Compared 2 methods Iodophor Scrub/Paint vs. Chlorhexidine-alcohol Result Significantly lower SSI rates with Chlorhexidine-alcohol prep for surperficial and deep incisional wounds
Clear as Mud……..
Prewash prior to application Follow manufacturers directions Utilize proper aseptic technique during application & gloves to contain shedding
Optimal dressings are: Permeable to gas exchange Impermeable to microbes/contamination Create a moist healing environment (37°C)
Stay in place Good adherence properties Change on day 2-3 unless drainage, dirty, or damaged Use proper aseptic technique when applying the dressings before the drapes are removed Partner with Wound Care Specialists Sussman, C, Bates-Jensen, B. Wound Care: A Collaborative Practice Manual for Health Professionals 2006; (Chap11)
The New Basics Glycemic Control Nasal Decolonization
30-35% of cardiac patients are diabetics SCIP INF 4: Cardiac surgery patients with controlled 6 a.m. postoperative serum glucose. The OR cannot be a black hole
Between 25-30% of all patients are colonized Another 60% carry it intermittently 85% of S. aureus infections were endogenous in SSI study populations Nasal decolonization should be considered due to the risk of S. aureus SSIs Van Rijen, et al. Intranasal Mupirocin for reduction of S. aureus in surgical patients with nasal carriage. J Anti Chemotherapy 2008; 61: Perl, TM, et al. Intranasal Mupirocin to Prevent Postoperative Staphylococcus Aureus Infections. N Engl J Med 2002; 346(24):
Speciality Specific Opportunities Cardiac Spinal Fusions Labor and Delivery Cath Lab
Cardiac Surgery 2 concurrent surgeries Skin antisepsis Bone wax Traffic and # of people Hypothermia
Spinal Surgery Equipment Amount, position, cleanliness Weiner, BK, Kilgore, WB. Bacterial shedding in common spine procedures: headlamp/loupes and the operative microscope. Spine 2007;32(8): Biswas, D, et al. Sterility of C-arm fluroscopy during spinal surgery. Spine 2008; 33(17): Antibiotics Redosing Time Longer surgeries, waiting for X-ray Dressings Posterior incisions (higher risk)
L&D and Cath Lab Aseptic technique Skin antisepsis
Facilitating Process Improvements 1. Provide the data Trend and report ABX and flash data monthly SSI Outcome data Quarterly 2. Utilize data to implement change NPSGs 3. Multidisciplinary- IP, Quality, nurses, techs, surgeons, anesthesia, schedulers, housekeeping
Process Improvements Make regular observations of aseptic technique Standardize Use forms to quantify when possible Simplify- pick one thing to get started
Process Improvements Implement Changes Seek out champions Communication is essential Get feedback from staff and re-evaluate prn Insure that new outcome data is communicated to staff Celebrate Success!