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Preventing Surgical Site Infections: Back to Basics

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Presentation on theme: "Preventing Surgical Site Infections: Back to Basics"— Presentation transcript:

1 Preventing Surgical Site Infections: Back to Basics
Kathleen Kohut, RN, MS, CIC, CNOR

2 Speaker Disclosures 3M AMN Healthcare BESmith The Compass Group

3 Objectives Name the 2 most common mechanisms for wound contamination
Discuss 7 areas of opportunity for improvement Describe the use of glycemic control and nasal decolonization initiatives for the reduction of SSIs. List 3 ways to facilitate process improvements in the Operating Room

4 Invaluable Resources National Healthcare Safety Network (NHSN)
1999 HICPAC SSI Guidelines AORN Guidelines Surgical Care Improvement Project (SCIP) Measures

5 SCIP Quality Measures Antibiotic Prophylaxis Drug, Timing, Dosing
Hair Removal Glycemic Control “Normothermia” Expanded in June All surgical patients

6 Back to the Basics Aseptic Technique Traffic Sterilization
ABX Prophylaxis Hair Removal Skin Antisepsis Dressings

7 1. Aseptic Technique Principles were developed to reduce the risk of wound contamination.

8 Defining the Risk of SSI
Risk of SSI = Dose of Bacterial Contamination X Virulence Resistance of Host (patient) Berry & Kohn’s, Operating Room Technique, 11th ed., p. 254

9 Causes of Wound Contamination
Exogenous sources Cleanliness of environment, lack of proper airflow, shedding by the Surgical Team Endogenous sources Patient’s own skin/hair Infection at a remote site

10 The Number One Source People = Shedding
,000 particles per minute (Berry & Kohn’s, Operating Room Technique, 11th ed., p. 252) Carried by wind currents to the sterile field which results in wound contamination. Patient Surgical Team Ancillary Personnel Sales Reps Students Passersby

11 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): Containment is the key

12 2. Traffic Control 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

13 People + Wind + (-) Aseptic Technique
Kohut SSI Equation People + Wind + (-) Aseptic Technique > ABX + Skin Prep = Wound Contamination = SSI

14 Containment is the key 1. Patient 2. Surgical Team 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)

15 Ban Skull Caps Dineen, P, Drusin, L. Epidemics of Postoperative Wound Infections Associated with Hair Carriers. Lancet 1973; (Nov)

16 Lack of Containment BAD VERY BAD

17 Standards of Excellence

18 Environment Room Requirements Room Cleaning
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)

19 Surgical Conscience 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);

20 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

21 Flash Sterilization Utilized for: Results in contamination due to:
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

22 Flash Data Calculation: # of flash events = rate x # of cases/month

23 4. Antibiotic Prophylaxis
SCIP Measures INF 1,2,3 Goal >90% Best Practice- Anesthesiologists Proper dosage for obese population (BMI>30) Don’t forget redosing q 3 hours

24 5. Hair Removal SCIP INF 6: Surgery patients with appropriate hair removal. Minimize as much as possible Clippers only Not in the OR!

25 6. Skin Antisepsis 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 )

26 Other Skin Antisepsis Considerations
Procedure Prep area Application Methodology Scrubbing vs. Painting Length of the procedure Challenges to the prep area -blood, saline, friction Patient Safety

27 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.

28 Current Recommendations
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

29 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

30 Current Research 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

31 Current Research 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.

32 Current Research Darouiche, RO, et al. Chlorhexidine-Alcohol versus Povidone-Iodine for Surgical-Site Antisepsis. N Engl J Med 2010; 362(1):18-26. 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

33 Clear as Mud……..

34 Product Application Prewash prior to application
Follow manufacturer’s directions Utilize proper aseptic technique during application & gloves to contain shedding

35 7. Dressings Optimal dressings are: Permeable to gas exchange
Impermeable to microbes/contamination Create a moist healing environment (37°C)

36 Dressings 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)

37 The “New Basics” Glycemic Control Nasal Decolonization

38 Glycemic Control 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

39 S. aureus Nasal Carriage
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):

40 Speciality Specific Opportunities
Cardiac Spinal Fusions Labor and Delivery Cath Lab

41 Cardiac Surgery 2 concurrent surgeries Skin antisepsis Bone wax
Traffic and # of people Hypothermia

42 Spinal Surgery Equipment Antibiotics Time Dressings
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)

43 L&D and Cath Lab Aseptic technique Skin antisepsis

44 Facilitating Process Improvements
Provide the data Trend and report ABX and flash data monthly SSI Outcome data Quarterly Utilize data to implement change NPSGs Multidisciplinary- IP, Quality, nurses, techs, surgeons, anesthesia, schedulers, housekeeping

45 Process Improvements Make regular observations of aseptic technique
Standardize Use forms to quantify when possible Simplify- pick one thing to get started

46 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!

47 Results After Process Improvements

48 Questions?

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