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 Disclosures3MAMN HealthcareBESmithThe Compass Group
3 Objectives Name the 2 most common mechanisms for wound contamination Discuss 7 areas of opportunity for improvementDescribe 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 GuidelinesAORN GuidelinesSurgical Care Improvement Project (SCIP) Measures
6 Back to the Basics Aseptic Technique Traffic Sterilization ABX ProphylaxisHair RemovalSkin AntisepsisDressings
7 1. Aseptic TechniquePrinciples were developed to reduce the risk of wound contamination.
8 Defining the Risk of SSI Risk of SSI = Dose of BacterialContamination X VirulenceResistance of Host (patient)Berry & Kohn’s, Operating Room Technique, 11th ed., p. 254
9 Causes of Wound Contamination Exogenous sourcesCleanliness of environment, lack of proper airflow, shedding by the Surgical TeamEndogenous sourcesPatient’s own skin/hairInfection 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.PatientSurgical TeamAncillary PersonnelSales RepsStudentsPassersby
11 Shedding plus Wind Currents Requires the control of:Amount of TrafficTraffic PatternsSherertz, 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 fieldSterile fields should be a destination, not a thoroughfareLimit students and observersThe right of the student to learn vs. the right of the patient to receive safe patient careDeKastle, R. Telesurgery: Providing Remote Surgical Observations for Students. AORN 2009; 90 (1):Utilize alternative methods of communication
14 Containment is the key 1. Patient 2. Surgical Team Pre-op Showers Hat and clean gown/linen for patient2. Surgical TeamHand HygieneNocardia farcinica (Wenger, et al. J Infect Dis. Nov 1998)Proper aseptic techniqueProperly worn hats, masks, clean OR scrubs, jackets, minimal jewelry (AORN scrub attire)
15 Ban Skull CapsDineen, P, Drusin, L. Epidemics of Postoperative Wound Infections Associated with Hair Carriers. Lancet 1973; (Nov)
17 Standards of Excellence PETA APPROVEDGOLD STANDARD
18 Environment Room Requirements Room Cleaning Ventilation System (15/hr – 3 fresh)Positive pressureTemperature (68-73° F)Humidity (30-60%)Room CleaningBetween casesTerminal cleaningTypes of construction materialsClutterAORN, Recommended Practices for Perioperative Nursing: Safe Environment of Care. (2008 ed., p 357)
19 Surgical ConscienceRequires 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 TechnologyWorkflowStaff certificationProper Sterilization ProcessesFocus area for The Joint CommissionCleaning, sterilization, and storage
21 Flash Sterilization Utilized for: Results in contamination due to: Dropped instrumentsPoorly designed work processesLack of instrumentationSurgeon schedulingResults in contamination due to:Poor cleaning due to lack of timeMethods of delivery to the sterile fieldClosed containers are best practiceTJC will be looking for themCarlo, A. The New Era of Flash Sterilization. AORN 2007: 86(1); p
22 Flash DataCalculation: # of flash events = rate x # of cases/month
23 4. Antibiotic Prophylaxis SCIP MeasuresINF 1,2,3Goal >90%Best Practice- AnesthesiologistsProper dosage for obese population (BMI>30)Don’t forget redosing q 3 hours
24 5. Hair RemovalSCIP INF 6: Surgery patients with appropriate hair removal.Minimize as much as possibleClippers onlyNot in the OR!
25 6. Skin AntisepsisThe attributes of an appropriate surgical skin antiseptic require:The ability to significantly reduce microorganisms (2 log, 3 log)Provide broad spectrum activityBe fast actingHave a persistent effectAll products with FDA approval meet this criteriaAORN, Recommended Practices for Perioperative Nursing: Skin Antisepsis. (2008 ed., pp )
26 Other Skin Antisepsis Considerations ProcedurePrep areaApplication MethodologyScrubbing vs. PaintingLength of the procedureChallenges to the prep area-blood, saline, frictionPatient 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 ResearchLimited research is available that compares commonly used skin antiseptic agents with SSI outcomesThe majority of the literature compares microbial countsThe correlation between microbial counts and SSI outcomes is unclear
30 Current ResearchSaltzman, MD, et al. Efficacy of Surgical Preparation Solutions in Shoulder Surgery. J Bone Joint Surg AM 2009;91:Microbial culture study of 150 patientsCompared 3 methodsIodophor Scrub/Paint vs. ChloraPrep® vs. Duraprep™ResultMicrobial counts were less using ChloraPrep®SSI Outcome was no SSIs in any of the groups
31 Current ResearchSwenson, 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 3209general surgery patientsCompared 3 methodsIodophor Scrub/ETOH/Paint vs. ChloraPrep® vs. DuraPrep™ResultSSI Outcomes- A statistical difference with lower SSI rates using iodine based products.
32 Current ResearchDarouiche, 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 patientsCompared 2 methodsIodophor Scrub/Paint vs. Chlorhexidine-alcoholResultSignificantly lower SSI rates with Chlorhexidine-alcohol prep for surperficial and deep incisional wounds
34 Product Application Prewash prior to application Follow manufacturer’s directionsUtilize proper aseptic technique during application & gloves to contain shedding
35 7. Dressings Optimal dressings are: Permeable to gas exchange Impermeable to microbes/contaminationCreate a moist healing environment (37°C)
36 Dressings Stay in place Good adherence propertiesChange on day 2-3 unless drainage, dirty, or damagedUse proper aseptic technique when applying the dressings before the drapes are removedPartner with Wound Care SpecialistsSussman, C, Bates-Jensen, B. Wound Care: A Collaborative Practice Manual for Health Professionals 2006; (Chap11)
37 The “New Basics”Glycemic ControlNasal 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 colonizedAnother 60% carry it intermittently85% of S. aureus infections were endogenous in SSI study populationsNasal decolonization should be considered due to the risk of S. aureus SSIsVan 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 CardiacSpinal FusionsLabor and DeliveryCath Lab
41 Cardiac Surgery 2 concurrent surgeries Skin antisepsis Bone wax Traffic and # of peopleHypothermia
42 Spinal Surgery Equipment Antibiotics Time Dressings Amount, position, cleanlinessWeiner, 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):AntibioticsRedosingTimeLonger surgeries, waiting for X-rayDressingsPosterior incisions (higher risk)
43 L&D and Cath LabAseptic techniqueSkin antisepsis
44 Facilitating Process Improvements Provide the dataTrend and report ABX and flash data monthlySSI Outcome data QuarterlyUtilize data to implement changeNPSGsMultidisciplinary- IP, Quality, nurses, techs, surgeons, anesthesia, schedulers, housekeeping
45 Process Improvements Make regular observations of aseptic technique StandardizeUse forms to quantify when possibleSimplify- pick one thing to get started
46 Process Improvements Implement Changes Seek out championsCommunication is essentialGet feedback from staff and re-evaluate prnInsure that new outcome data is communicated to staffCelebrate Success!
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