Introduction Please do not put your phone on hold; use the mute function or *6 Please type questions or comments into text box Interactive question session If time permits, we will open up the phone lines at the conclusion of the presentation
5 Beyond SCIP – SSI Preventi on Sue Barnes RN, BSN, CIC National Program Leader Infection Prevention & Control Kaiser Permanente
Objectives 1. Discuss strategies to optimize 4 specific SCIP measures, beyond regulatory compliance 2. Discuss 11 products and practices above and beyond SCIP – i.e. “plus” measures 3. Provide resources and references relative to “plus” measures 6
8 SCIP Measures http://intranet.uchicago.edu/quality/SCIP_files/page0001.htm SCIP INF 1 Prophylactic antibiotic received within one hour prior to surgical incision SCIP INF 2 Prophylactic antibiotic selection for surgical patients SCIP INF 3 Prophylactic antibiotics discontinued within 24 hours after surgery end time (48 hours for cardiac patients) SCIP INF 4 Cardiac surgery patients with controlled 6 a.m. post op serum glucose (200 mg/dL) SCIP INF 6 Surgical patients with appropriate hair removal SCIP INF 7 Colorectal surgical patients with immediate postoperative normothermia SCIP INF 9 Urinary catheter removed on post op day 1 SCIP INF 10 Surgery patients with perioperative temperature management
10 3 grams Ancef for Bariatric Patients 1.Freeman JT, Anderson DJ, Hartwig MG, Sexton DJ. “Surgical site infections following bariatric surgery in community hospitals: a weighty concern?” Obes Surg. 2011 Jul;21(7):836-40.Freeman JTAnderson DJHartwig MGSexton DJObes Surg. 2.Pevzner L, Swank M, Krepel C, Wing DA, Chan K, Edmiston CE Jr. “Effects of maternal obesity on tissue concentrations of prophylactic cefazolin during cesarean delivery”. Obstet Gynecol. 2011 Apr;117(4):877-82.Pevzner LSwank MKrepel CWing DAChan K Edmiston CE JrObstet Gynecol. 3.Roe JL, Fuentes JM, Mullins ME. “Under dosing of common antibiotics for obese patients in the ED”. Am J Emerg Med. 2011 Dec 12. [Epub ahead of print]Roe JLFuentes JMMullins MEAm J Emerg Med.
12 SAFE Pre-op Hair Removal Removal outside of OR or clipper with vacuum Pre op patient teaching no leg shaving Disposable clipper head or reprocess b/w patients 1.Adisa AO, Lawal OO, Adejuyigbe O. “Evaluation of two methods of preoperative hair removal and their relationship to postoperative wound infection”. J Infect Dev Ctries. 2011 Oct 13;5(10):717-22.Adisa AOLawal OOAdejuyigbe OJ Infect Dev Ctries. 2.Broekman ML, van Beijnum J, Peul WC, Regli L. “Neurosurgery and shaving: what's the evidence?” J Neurosurg. 2011 Oct;115(4):670-8. Epub 2011 Jul 1.Broekman MLvan Beijnum JPeul WCRegli LJ Neurosurg. 3.Diana M, Hübner M, Eisenring MC, Zanetti G, Troillet N, Demartines N. “Measures to prevent surgical site infections: what surgeons (should) do”. World J Surg. 2011 Feb;35(2):280-8.Diana MHübner MEisenring MCZanetti GTroillet N Demartines NWorld J Surg.
13 Unless your patient looks like this, consider NOT clipping hair Mangram AJ et al. Guideline for prevention of surgical site infection, 1999. Hospital Infection Control Practices Advisory Committee. Infect Control Hosp Epidemiol 1999; 20:250 ‐ 278; quiz 279 ‐ 280.
15 Normothermia 1.Esnaola NF, Cole DJ. “Perioperative normothermia during major surgery: is it important?” Adv Surg. 2011;45:249-63.Esnaola NFCole DJAdv Surg. 2.Hart SR, Bordes B, Hart J, Corsino D, Harmon D. “Unintended perioperative hypothermia”. Ochsner J. 2011 Fall;11(3):259-70.Hart SRBordes BHart JCorsino DHarmon DOchsner J. 3.Moola S, Lockwood C. “Effectiveness of strategies for the management and/or prevention of hypothermia within the adult perioperative environment”. Int J Evid Based Healthc. 2011 Dec;9(4):337-45.Moola SLockwood CInt J Evid Based Healthc.
16 Glucose Control = minimizing extremes 1.Chi A, Lissauer ME, Kirchoffner J, Scalea TM, Johnson SB. “Effect of glycemic state on hospital mortality in critically ill surgical patients”. Am Surg. 2011 Nov;77(11):1483-9.Chi ALissauer MEKirchoffner JScalea TMJohnson SBAm Surg. 2.Martinez EA, Chavez-Valdez R, Holt NF, Grogan KL, Khalifeh KW, Slater T, Winner LE, Moyer J, Lehmann CU. “Successful implementation of a perioperative glycemic control protocol in cardiac surgery: barrier analysis and intervention using lean six sigma”. Anesthesiol Res Pract. 2011;2011:565069. Epub 2011 Sep 6.Martinez EAChavez-Valdez RHolt NFGrogan KLKhalifeh KW Slater TWinner LEMoyer JLehmann CUAnesthesiol Res Pract. 3.Pichardo-Lowden A, Gabbay RA. “Management of Hyperglycemia During the Perioperative Period”. Curr Diab Rep. 2011 Nov 12. [Epub ahead of print]Pichardo-Lowden AGabbay RACurr Diab Rep. 4.Stawicki S, Schuster D, Liu J, Kamal J, Erdal S, Gerlach A, Whitmill M, Lindsey D, Murphy C, Steinberg S, Cook C. “The glucogram: A new quantitative tool for glycemic analysis in the surgical intensive care unit”. Int J Crit Illn Inj Sci. 2011 Jan;1(1):5- 12.Stawicki SSchuster DLiu JKamal JErdal SGerlach A Whitmill MLindsey DMurphy CSteinberg SCook CInt J Crit Illn Inj Sci.
18 Eliminate or cover cloth skull cap when in surgery Double gloving Change sterile gloves before closing Permit ONLY scrubs laundered by hospital Red caps for visitors Attire - Surgical
Double Gloving: Phillips S. “The comparison of double gloving to single gloving in the theatre environment.” J Perioper Pract. 2011 Jan;21(1):10-5. Phillips SJ Perioper Pract.Phillips SJ Perioper Pract. Changing gloves: Epstein NE. “Preoperative, intraoperative, and postoperative measures to further reduce spinal infections.” Surg Neurol Int. 2011 Feb 21;2:17. Epstein NE Surg Neurol Int.Epstein NE Surg Neurol Int. Hair coverage :Frey K, Ross T. eds. Surgical Technology for the Surgical Technologist: A Positive Care Approach. 3rd ed. Clifton Park, NY: Delmar Cengage; 2008. Scrubs: Belkin NL. Home laundering of soiled surgical scrubs. American Journal of Infection Control. 2001; 29: 58-64. 19 Attire - Surgical
Blood - Minimizing Transfusions 1. Young H. Et al. “Statewide collaboration to evaluate the effects of blood loss and transfusion on surgical site infection after hysterectomy”. ICHE Jan 2012, Vol. 33, No 1 pp 90-93. 2. Schwarzkopf R et al. “Effects of Perioperative Blood Product Use on Surgical Site Infection Following Thoracic and Lumbar Spinal Surgery”. Spine. 2010;35(3):340-346. 3. Pulido L, Ghanem E, Joshi A, et al. Periprosthetic joint infection: the incidence, timing, and predisposing factors. Clin Orthop Relat Res. 2008; 466(7):1710-1715. 4. Talbot TR et al. “Perioperative Blood Transfusion Is Predictive of Poststernotomy Surgical Site Infection: Marker for Morbidity or True Immunosuppressant?” Clinical Infectious Diseases 2004; 38:1378–82 21
Olson LK et al. “Prospective, randomized in vivo comparison of a dual-active waterless antiseptic versus two alcohol-only waterless antiseptics for surgical hand antisepsis”. American Journal of Infection Control Volume 40, Issue 2, March 2012, Pages 155–159. American Journal of Infection Control Volume 40, Issue 2American Journal of Infection Control Volume 40, Issue 2 Usavadee Asdornwised “An Evaluation of Brush, Brushless, and Waterless Surgical Hand Scrubs among Health Care Workers in Operating Rooms at a University Hospital in Thailand “. J Nurs Sci Vol.29 No.3 July- September 2011. 25 Hand Scrub - Brushless & Dual Agent
27 Irrigation: Intra-operative 1.COPIOUS IRRIGATION - Watanabe M, Sakai D, Matsuyama D, Yamamoto Y, Sato M, Mochida J. “Risk factors for surgical site infection following spine surgery: efficacy of intraoperative saline irrigation”. J Neurosurg Spine. 2010 May;12(5):540-6.Watanabe MSakai DMatsuyama DYamamoto YSato MMochida JJ Neurosurg Spine. 2.CHG - Han Y, Giannitsios D, Duke K, Steffen T, Burman M. “Biomechanical analysis of chlorhexidine power irrigation to disinfect contaminated anterior cruciate ligament grafts”. Am J Sports Med. 2011 Jul;39(7):1528-33.Han YGiannitsios DDuke KSteffen TBurman MAm J Sports Med. 3.PULSATILE - Nikfarjam M, Kimchi ET, Gusani NJ, Avella DM, Shereef S, Staveley-O'Carroll KF. “Reduction of surgical site infections by use of pulsatile lavage irrigation after prolonged intra-abdominal surgical procedures”. Am J Surg. 2009 Sep;198(3):381-6.Nikfarjam MKimchi ETGusani NJAvella DM Shereef SStaveley-O'Carroll KFAm J Surg. 4.OPHTHALMOLOGY - Fernandes M, Pathengay A. “Reduction of anterior chamber contamination rate after cataract surgery by intraoperative surface irrigation with 0.25% povidone-iodine”. Am J Ophthalmol. 2011 Aug;152(2):320; author reply 320-1.Fernandes MPathengay AAm J Ophthalmol.
OR Observations 28 “Almost no matter what experimental conditions were imposed, increases in output occurred….The investigators had obviously influenced the subjects’ behavior merely by studying that behavior, and this phenomenon has become known as the Hawthorne effect.” (Kelly Shaver, Principles of Social Psychology, 2 nd ed., Winthrop, 1981)
Qadan M, Akça O, Mahid SS, Hornung CA, Polk HC Jr. “Perioperative supplemental oxygen therapy and surgical site infection: a meta-analysis of randomized controlled trials.” Arch Surg. 2009 Apr;144(4):359-66; discussion 366-7. Qadan MAkça OMahid SSHornung CAPolk HC JrArch Surg. Qadan MAkça OMahid SSHornung CAPolk HC JrArch Surg. James T. Lee, MD, PhD “Supplemental Oxygen and Risk of Surgical Site Infection”JAMA 2004;291(16):1957-1958. James T. Lee, MD, PhD “Supplemental Oxygen and Risk of Surgical Site Infection”JAMA 2004;291(16):1957-1958. James T. Lee James T. Lee Hopf H, Hunt T, Rosen N. “Supplemental Oxygen and Risk of Surgical Site Infection”. JAMA. 2004;291(16):1956. 30 O 2 - Supplemental
31 Estimates of costs/mortality associated with infections Skin Antisepsis
1. SKIN - Lee I, Agarwal RK, Lee BY, Fishman NO, Umscheid CA. “Systematic review and cost analysis comparing use of chlorhexidine with use of iodine for preoperative skin antisepsis to prevent surgical site infection”. Infect Control Hosp Epidemiol. 2010 Dec;31(12):1219-29. Lee IAgarwal RKLee BYFishman NOUmscheid CAInfect Control Hosp Epidemiol.Lee IAgarwal RKLee BYFishman NOUmscheid CAInfect Control Hosp Epidemiol. 2. SKIN- Bailey RR, Stuckey DR, Norman BA, Duggan AP, Bacon KM, Connor DL, Lee I, Muder RR, Lee BY Economic value of dispensing home- based preoperative chlorhexidine bathing cloths to prevent surgical site infection. Infect Control Hosp Epidemiol. 2011 May;32(5):465-71. Economic value of dispensing home- based preoperative chlorhexidine bathing cloths to prevent surgical site infection.Economic value of dispensing home- based preoperative chlorhexidine bathing cloths to prevent surgical site infection. 3. NASAL - Pofahl WE, Ramsey KM, Nobles DL, Cochran MK, Goettler C. “Importance of methicillin-resistant Staphylococcus aureus eradication in carriers to prevent postoperative methicillin-resistant Staphylococcus aureus surgical site infection”. Am Surg. 2011 Jan;77(1):27-31. Pofahl WERamsey KMNobles DLCochran MKGoettler CAm Surg.Pofahl WERamsey KMNobles DLCochran MKGoettler CAm Surg. 4. ORAL - Segers P, Speekenbrink RG, Ubbink DT, van Ogtrop ML, de Mol BA. “Prevention of nosocomial infections after cardiac surgery by decontamination of the nasopharynx and oropharynx with chlorhexidine; a prospective, randomised study”. Ned Tijdschr Geneeskd. 2008 Mar 29;152(13):760-7. Segers PSpeekenbrink RGUbbink DTvan Ogtrop MLde Mol BANed Tijdschr Geneeskd.Segers PSpeekenbrink RGUbbink DTvan Ogtrop MLde Mol BANed Tijdschr Geneeskd. 32
33 Skin Antisepsis: Pre-op bathing with CHG cloths Also used as pre-op skin prep for emergency C-sections
Wound Edge Protector 1. Green C, Molony D, Cashman J, Burke T, Masterson E. “Another string.... but no bow”. Acta Orthop Belg. 2011 Apr;77(2):258-9. Green CMolony DCashman JBurke TMasterson EActa Orthop Belg. Green CMolony DCashman JBurke TMasterson EActa Orthop Belg. 2. Kadowaki Y, Kurokawa T, Tamura R, Okamoto T, Ishido N, Mori T. “Lap-Protector and Circular Stapler Are Useful in Cystogastrostomy for Large Pancreatic Pseudocyst with Severe Infection”. Case Rep Gastroenterol. 2010 Jul 21;4(2):215-219. Kadowaki YKurokawa TTamura ROkamoto TIshido N Mori TCase Rep Gastroenterol. Kadowaki YKurokawa TTamura ROkamoto TIshido N Mori TCase Rep Gastroenterol. 3. Nakamura Y, Matsumoto S, Tajiri T, Uchida E. “A safe technique for laparoscopic distal pancreatectomy involving a large cystic tumor”. J Nihon Med Sch. 2011;78(6):374-8. Nakamura YMatsumoto STajiri TUchida EJ Nihon Med Sch. Nakamura YMatsumoto STajiri TUchida EJ Nihon Med Sch. 39