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Loretta Litz Fauerbach, MS, CIC

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1 Surgical Site Infections: Meeting the Latest Standards & Assuring A SafeEnvironment for Prevention
Loretta Litz Fauerbach, MS, CIC Fauerbach & Associates – Global Infection Prevention Services March 7, 2013 Taking Quality to the Next Level Kentucky Hospital Association Annual Quality Conference and Hospital Engagement Network Convening Louisville, Kentucky

2 Objectives To identify the components in the Surgical Care Improvement Project To discuss CMS SSI reporting requirements to NHSN To clarify NHSN methodology To identify other quality initiatives related to SSI prevention To identify key stake holders and reporting mechanisms for a strong surgical site infection prevention program. To identify challenges with data collection and strategies to improve communications related to identifying surgical site infections To discuss accrediting and licensing requirements related to SSI prevention LLF SSI Standards 2013

3 Impact of SSIs Occur in 2%-5% of patients undergoing inpatient
surgery in the United States. Approximately 500,000 SSIs occur each year 7-10 additional post operative hospital days 2-11 times higher risk of death compared to patients who do not have an SSI Patients with an SSI have a 2-11 times higher risk of death, compared with operative patients without an SSI. 77% of deaths in patients who have an SSI are directly attributable to SSI Attributable costs vary depending on procedure and organisms but range from $3000 to $29,000 SSIs are believed to account for up to $10 billion annually in healthcare expenditures. LLF SSI Standards 2013

4 SSI Burden of Illness Surgical Site Infections:
Represent 20 percent of all health care-associated infections reported to the National Nosocomial Infections Surveillance System (NNIS) in 2002. Result in more than 8,000 deaths a year and occur in up to 25 percent of patients following major surgical procedures. Extend average length of stay by 9.7 days while increasing cost by $20,842 per admission. Are preventable in an estimated 40 to 60 percent of cases.

5 Surgical Site Infections (SSI’s) General Background
2.6% of 30 million operations complicated by SSI’s SSI’s Second most common healthcare associated infection accounting for 17% of all hospital acquired infections SSI’s most common healthcare associated infection in surgical patients (38%) Consequences of SSI Increased hospital stay by up to 10 days Increased hospital costs Increased readmission rates Increased pain and suffering CDC, 2003 LLF SSI Standards 2013

6 National Patient Safety Goal
NPSG Implement best practices for preventing surgical site infections. CDC Guideline for the Prevention of Surgical Site Infections SHEA Compendium IHI Bundle Care LLF SSI Standards 2013

7 Health & Human Services Infection Prevention Plan for Surgical Site Infections
SSI 1 Deep incision and organ space infection rates using NHSN definitions (SCIP procedures) Goal: CDC NHSN Median deep incision and organ space infection rate for each procedure/risk group will be at or below the current NHSN 25th percentile Measure: Surgical site infection rate: Deep wound and organ space infections as a result of elective surgery to include coronary artery bypass graft (CABG) and cardiac surgery; hip or knee arthroplasty; colon surgery; hysterectomy (abdominal and vaginal); and vascular surgery. LLF SSI Standards 2013

8 Health & Human Services Infection Prevention Plan for Surgical Site Infections
SSI 2 Adherence to SCIP/NQF infection process measures (perioperative antibiotics, hair removal, postoperative glucose control, normothermia) CMS SCIP Goal: 95% adherence rates to each SCIP/NQF infection process measure. Cardiac surgery patients with controlled postoperative serum glucose; Surgery patients with appropriate hair removal; Prophylactic antibiotics received; Prophylactic antibiotics selection; Prophylactic antibiotics discontinued Measure: Compliance with Centers for Medicare and Medicaid Services antimicrobial prophylaxis guidelines. LLF SSI Standards 2013

9 Evidence-Based Practice Guidelines for Surgical Site Infection Prevention
Four components of care include: 1. Appropriate use of prophylactic antibiotics Prophylactic antibiotic received within one hour prior to surgical incision Prophylactic antibiotic selection for surgical patients consistent with national guidelines Prophylactic antibiotics discontinued within 24 hours after surgery end time (48 hours for cardiac patients) 2. Appropriate hair removal (if deemed necessary, remove using clippers or depilatory)

10 Evidence-Based Practice Guidelines for Surgical Site Infection Prevention
3. Controlled postoperative serum glucose in cardiac surgery Glucose control is defined as serum glucose levels below 200 mg/dl, collected at or closest to 6:00 a.m. on each of the first two postoperative days Tight glucose control (using an insulin drip) is often performed in an intensive care setting 4. Immediate postoperative normothermia in colorectal surgery LLF SSI Standards 2013

11 Evidence-Based Practice Guidelines for Surgical Site Infection Prevention
Additional SCIP changes in care: Beta blockade for patients on beta blockers prior to admission should be continued postoperatively Venous thromboembolism prophylaxis Ventilator-associated pneumonia prevention Source: Institute for Healthcare Improvement, How-to Guide: Prevent Surgical Site Infections. (2012) Accessed 7/11/12. LLF SSI Standards 2013

12 The Florida Surgical Care Initiative (FSCI)
A partnership between the Florida Hospital Association (FHA) and the American College of Surgeons (ACS), and endorsed by the Florida Chapter of the ACS, Focus initially on four outcome measures of the ACS National Surgical Quality Improvement Program (NSQIP) LLF SSI Standards 2013

13 FSCI Surgical Outcome Measures
Standard ACS NSQIP* measures that are followed from pre-op to 30 days post-discharge surgical site infection (SSI), urinary tract infection (UTI), colorectal outcomes and elderly surgery outcomes * ACS NSQIP - significantly decrease patient mortality and morbidity rates (Annals of Surgery, 250: , September 2009) LLF SSI Standards 2013

14 LLF SSI Standards 2013

15 FSCI Unique Approach to Measurement
Uses medical chart data gathered by clinically trained personnel rather than insurance claims data derived from medical bills Adjusts for risk so that the patient’s condition is taken into consideration when assessing the outcome Evaluates how the patient is doing a month after his or her operation, since more than half of complications occur after discharge Builds commitment and collaboration among surgeons, surgical teams and hospitals, because it is based on the highest quality data LLF SSI Standards 2013

16 FSCI Surgical Outcome Measures
LLF SSI Standards 2013

17 Ambulatory Surgery Care Standards
CMS State Operations Manual, Appendix L, Part I ASC Survey Protocol, and Part II General Conditions and Requirements May also be accessed through the website Very Similar to CMSCDC/SHEA/TJC recommendations for hospitals LLF SSI Standards 2013

18 ASC Infection Control The ASC must maintain an infection control program that seeks to minimize infections and communicable diseases LLF SSI Standards 2013

19 ASC Key Elements of a Risk Assessment
Make it your own through a formal Risk Assessment Collaborative effort Regularly reviewed and updated Governing body review Forms the basis for your written Infection Prevention Plan including goals and measureable objectives LLF SSI Standards 2013

20 Risk Assessment for Facility’s Unique Practice Setting
Identify Risks for Transmission Populations Procedures – general and specialty care procedures Geographic Location/Weather Size of Facility Referral Patterns Organisms and risks common to the community (endemic occurrences) Surveillance data including HAIs and process monitoring Construction Cleaning, Disinfection Sterilization Supply Chain Staffing Medical ASC staff LLF SSI Standards 2013

21 Types of Infections Surgical Site Infections CA-UTI
Intravenous Catheters including CLA-BSIs C. difficile or other GI pathogens Respiratory Illness Resistant Organisms LLF SSI Standards 2013

22 Collaboration is Key Part of IP Risk Assessment
Interdisciplinary Input Infection Prevention Team Medical Staff Nursing Staff Administration Other Leaders Other potential participants Patients Public Relations Public Health 3rd Party Payors LLF SSI Standards 2013

23 Set Goals Based on Risk Assessment
High Risk - High Volume Likelihood of event occurring Key Risks Determine top priority Set Goals Establish measurements to evaluate goals Set protocols for obtaining the data for the measurements LLF SSI Standards 2013

24 Infection Prevention Program and QA/PI Program Linkage
416.51(b) …”ongoing program designed to prevent, control, and investigate ..” 416.51(b)(2) …”an integral part of the ASC’s quality assessment and performance improvement program..” LLF SSI Standards 2013

25 Basic Program Elements
SSI Prevention Hand Hygiene Cleaning, Disinfection and Sterilization Safe Injection Practices LLF SSI Standards 2013

26 Qualified IP Required Condition for Coverage – Infection Control: “The ASC’s infection control program must be directed by a designated health care professional with training in infection control.” ICSW Item #17 – “Does the ASC have a licensed health care professional qualified through training in IC and designated to direct the ASC’s IC program?” LLF SSI Standards 2013

27 Impact of ICSW Item #17: “If the ASC cannot document it has designated a qualified professional with training in IC to direct its IC program, a deficiency must be cited. Lack of a designated professional responsible for IC should be considered .. for a Condition level deficiency related to ” LLF SSI Standards 2013

28 Common Citations Written materials are needed, yet are absent, incomplete, or insufficient to meet the standards Cleaning, disinfection, and sterilization of instruments, equipment and supplies, environmental cleaning Governing body formal meeting minutes Policies & procedures Required recordkeeping such as logs Evidence of delegation of responsibilities Evidence of compliance with policies Manufacturer’s Recommendations Follow AAMI, AORN, CDC LLF SSI Standards 2013

29 Common Citations One Needle, One Syringe, One Patient, One Time
Safe Injection Practices One Needle, One Syringe, One Patient, One Time Outbreaks due to improper use of single dose vials, syringes and needles Single patient use vials are single patient use, unless drawn up under a certified pharmacy hood, no exceptions! Nationally recognized guidelines adopted by your organization’s Governing Body as evidenced in formal meeting minutes Most current version Adherence Education Surveillance LLF SSI Standards 2013

30 Common Citations Procedures to minimize risk of Infection including Surveillance NHSN CDC Guidelines Patient Safety Goals AORN Process Monitoring Outcome Monitoring Targeted activities- high risk /high volume Legislative Mandates Definitions Methodology Comparisons LLF SSI Standards 2013

31 Tips for Success for Accreditation Survey
Present the most current standards book upfront. Prepare for the challenging aspects Set up a space for the surveyor to work Document quality and infection prevention initiatives Prepare a list of physicians and staff Make sure credentials are in order Have evaluations and education/orientation records readily available LLF SSI Standards 2013

32 Key Resources Accreditation Association for Ambulatory Health Care
for general questions Association for Professionals in Infection Control Safe Injection Practices Center for Disease Control LLF SSI Standards 2013

33 Basic practices for prevention and monitoring of SSI:
1. Perform surveillance for SSI (A-II). 2. Provide ongoing feedback on SSI surveillance and process measures to surgical and perioperative personnel and leadership (A-II). 3. Increase the efficiency of surveillance through the use of automated data (A-II). LLF SSI Standards 2013 CDC SSI Guideline 1999

34 SSI Surveillance Methods
Daily Direct Observation by trained person starting hours after surgery Considered to be the most accurate method of surveillance, but rarely used due to resource limitation Indirect SSI surveillance using a combination of sources Microbiology and Patient Records Survey of surgeons and patients Re-admission tracking Other information including coded dx, or op reports Efficacy of Indirect Surveillance Less time consuming, IP can perform during surveillance rounds Reliable (sensitivity, 84%-89%) and specific (specificity, 99.8%) when compared to “gold standard” of direct surveillance. LLF SSI Standards 2013 CDC SSI Guideline 1999

35 Automated Surveillance
Expanded by using hospital databases data on administrative claims, days of antimicrobial use, readmission to the hospital, return to the operating room Automatically import data microbiologic culture data, surgical procedure data, and general demographic information Improve the sensitivity of indirect surveillance for detection of SSI Improve IP efficiency in data collection LLF SSI Standards 2013 CDC SSI Guideline 1999

36 Perform Surveillance High Risk - High Volume
Identify, collect, store, and analyze data needed for the surveillance program. Implement a system for collecting data needed to identify SSIs. Develop a database for storing, managing, and accessing collected data on SSIs. Prepare periodic SSI reports (the time frame will depend on hospital needs and volume of targeted procedures). LLF SSI Standards 2013 CDC SSI Guideline 1999

37 Perform Surveillance Collect denominator data on all patients undergoing targeted procedures, to calculate SSI rates for each type of procedure Identify trends (eg, in rates of SSI and pathogens causing SSIs). Use CDC and NHSN definitions of SSI Perform indirect surveillance for targeted procedures. Perform postoperative surveillance for 30 days; if prosthetic material is implanted during surgery then follow for 12 months LLF SSI Standards 2013 CDC SSI Guideline 1999

38 Special Approaches for SSI Prevention
Perform an SSI Risk Assessment Perform Expanded SSI Surveillance Determine the source, extent of the problem, and to identify potential interventions Case finding Observational Studies Check adherence rates to best practices Identify areas that surveillance data suggest lack of effective control. Elements to Consider High Risk -High Volume Surveillance Data Rates Processes Organisms Strategies LLF SSI Standards 2013 CDC SSI Guideline 1999

39 Post Discharge SSI Surveillance
More Procedures are being done in outpatient setting Shorter Post OP stays for Inpatients No standard method for Post OP SSI surveillance Questionnaires to patients, surgeons, or clinics Shown to have poor sensitivity and specificity Rates do increase after Post Op Surveillance implemented Superficial incisional infections usually managed as outpatient Deep incisional and organ/space infections typically require readmission to the hospital for management. LLF SSI Standards 2013 CDC SSI Guideline 1999

40 LLF SSI Standards 2013

41 Infrastructure Requirements
Trained personnel Infection prevention and control personnel SSI surveillance, Able to apply CDC definitions of SSI, Basic computer and mathematical skills, and Good communication skills and adept at providing feedback and education to healthcare personnel when appropriate NSQIP – surveillance nurse LLF SSI Standards 2013 CDC SSI Guideline 1999

42 Computer Assisted Decision Support Creating automatic reminders
Use computer support to improve pre-op administration of antimicrobial prophylaxis Initial and repeat doses Stop orders Utilization of automated data Tracking Monitoring LLF SSI Standards 2013

43 Feedback Provide ongoing feedback on SSI surveillance and process measures to surgical and perioperative personnel and leadership (A-II). Routinely provide feedback on SSI rates and process measures to individual surgeons and hospital leadership. For each type of procedure performed, provide risk adjusted rates of SSI. Anonymously benchmark procedure-specific risk adjusted rates of SSI among peer surgeons. Confidentially provide data to individual surgeons, the surgical division, and/or department chiefs. LLF SSI Standards 2013

44 Will automation and reminders help?
30% of SSI are preventable with appropriate use of preoperative antibiotics* LLF SSI Standards 2013 *Dellinger EP 2005

45 Prevention of SSI: Process
MD to treat any existing infection at remote site (urine, bloodstream, etc.) Remove hair only when necessary Do not shave When necessary, use clippers or depilatories Control hyperglycemia Implement preoperative showers--CHG preferred Administer surgical prophylaxis according to guidelines Maintain appropriate oxygenation control Maintain normothermia/control of hypothermia CDC SSI Guideline 1999 LLF SSI Standards 2013

46 SSI Complexity Microbial characteristics (eg, degree of contamination and virulence of pathogen) Patient characteristics (eg, immune status and comorbid conditions) Surgical characteristics (eg, type of procedure, introduction of foreign material, and amount of damage to tissues) LLF SSI Standards 2013

47 Extrinsic Procedure Related Perioperative: Patient Preparation
Hair Removal Pre-Operative Infections Do not remove hair unless hair will interfere with the operation If hair removal is necessary remove by clipping. Do not use razor. A I Identify and treat remote infections prior to elective surgical procedures. A II CDC SSI Guideline 1999 LLF SSI Standards 2013

48 SSI Prevention Guidelines Preparation of Patient
Do Not Remove Hair at the incision site, unless it will interfere with surgery itself. If the hair must be removed, do it directly beforehand, preferably with electric clippers. (1A) Pre-surgical patients should perform an antiseptic shower at least the night before and preferably also the morning of the scheduled surgery. Wash and clean the incision site area, scrubbing lightly to remove any gross skin contamination prior to antiseptic surgical preparation. (1B) CDC, 1999 LLF SSI Standards 2013

49 Hair Removal Method Shaving versus Clipping
Clean Wound Infection Rate (%) Shaved with razor 2.5 Clipped 1.7 Electric razor 1.4 Not shaved, not clipped 0.9 Depilatories 0.6 The increased risk with shaving prior to the operation is associated with microscopic cuts and shaving immediately before seriously reduces the SSI risk ( 20% risk if shaved > 24hrs--CDC, 1999). Cruce and Forde, 1981 LLF SSI Standards 2013

50 Implement evidence based standards (A-II)
Policies and practices should include but are not limited to the following: Reducing modifiable patient risk factors Optimal cleaning and disinfection of equipment and the environment Optimal preparation and disinfection of the operative site and the hands of the surgical team members Adherence to hand hygiene Traffic control in operating rooms LLF SSI Standards 2013 CDC SSI Guideline 1999

51 Intrinsic Patient Related - Perioperative
Modifiable Un-Modifiable Obesity Increase dosing pre-op antimicrobial prophylaxis for morbidly obese patients.A-II Smoking Cessation Encourage within 30 days before procedure A-II Immunosuppressive Meds No formal recommendations Avoid if possible in perioperative period if possible.C-II Glucose Control, diabetes Control serum glucose levels Reduce glycosylated hemoglobin A1c levels to <7% before surgery, if possible Un-modifiable Age No formal recommendation: relationship to increased SSI due to comorbidities or immune status. LLF SSI Standards 2013 CDC SSI Guideline 1999

52 Operative Characteristics
Surgical Scrub Use appropriate antiseptic agent to perform 2-5 minute preoperative surgical scrub or an alcohol-based surgical hand antiseptic product. A-II Skin Preparation Wash and clean skin around incision site; use an appropriated antiseptic agent. A-II LLF SSI Standards 2013 CDC SSI Guideline 1999

53 Operative Characteristics
Surgical skill/technique Handle tissue carefully and eradicate dead space (A-III) Antisepsis Adhere to standard principles of operating room asepsis (A-III) Operative Time No formal recommendation in most recent guidelines; minimize as much as possible (A-III) LLF SSI Standards 2013 CDC SSI Guideline 1999

54 Operative Characteristics - Operating Room
Ventilation Follow AIA recommendations (C-I) Traffic Minimize operating room traffic (B-II) Environmental Surfaces Use a US Environmental Protection Agency-approved hospital disinfectant to clean surfaces and equipment. (B-III) Sterilization of surgical equipment Sterilize all surgical equipment according to published guidelines (B-II) Minimize the use of flash sterilization LLF SSI Standards 2013 CDC SSI Guideline 1999

55 Sterile Gowns Select Sterile gowns
When you will be at the sterile field When you are inserting a central line Select based on level of potential blood exposure Impervious Fluid Resistant Twirl for closure and Tie securely Maintain sterile area Sides and back are not considered sterile Do not turn side or back to sterile field within 12 inches LLF SSI Standards 2013 CDC SSI Guideline 1999

56 Gowns Key for in use sterility
Side, back and below table areas are non-sterile Sterile above the table Shaded portion indicates protective barrier zones LLF SSI Standards 2013

57 Drapes Key for In Use Sterility
Protective Barrier Not part of sterile field when below table Sterile during procedure LLF SSI Standards 2013

58 Gowns for Non-scrubbed Personnel
Select gown for blood borne pathogen protection requirements How likely are you to be splattered during a procedure? How likely are you to contaminate yourself with potentially infectious material Is the patient on isolation precautions? LLF SSI Standards 2013

59 Lead Aprons Establish cleaning procedure After use
Inspect prior to procedure to make sure they are clean and ready to go Hang and store to prevent contamination by splashing LLF SSI Standards 2013

60 General Infection Control for Non-scrubbed Participants
Hand Hygiene Prior to entry of OR After touching patient or patient’s equipment During procedure as appropriate Wear gloves if likely to be contaminated with blood or body fluids Wear mask appropriately LLF SSI Standards 2013

61 Hand Hygiene Plus Changing Gloves is critical for infection prevention
Alcohol gel : Place on cart or desk for easy access and use Perform hand hygiene and don clean gloves before and after handling patient devices IV, Foley, etc Perform hand hygiene before and after positioning patient LLF SSI Standards 2013

62 General Infection Prevention for Non-scrubbed Participants
Use appropriate technique to enter vials Clean top with alcohol - do not just pop or access without cleaning Maintain distance from sterile field Non-sterile participants must maintain at least a 12” distance from sterile field Minimize talking Minimize moving around in room Maintain all precautions until surgery is completed and surgical site is closed LLF SSI Standards 2013

63 Room Set Up Sterile field tables Maintain sterility of equipment cover
Make sure tables are clean before starting to set up the room Set up using sterile technique Evaluate the amount of items that are opened and on sterile table Room Set Up Anesthesia Cart Maintain sterility of equipment cover Do not turn back to equipment Sterile field tables Set up so there is 1’ clearance for staff to work between tables Do not turn back to sterile field within 1’ All non-scrubbed staff must maintain distance P a t i e n Below table tops are not sterile - do not bend down or turn to side LLF SSI Standards 2013

64 OR Traffic Flow Personnel must enter by sub-sterile room
Enter by larger corridor door only when Bringing patient into room Bringing large equipment into room Do not enter by larger doors during procedure May enter if a piece of equipment is absolutely necessary for case Keep doors to corridor closed at all times except for above situations (1&2) LLF SSI Standards 2013

65 Equipment & Product Reps
If going to be near sterile field to assist in equipment utilization, representative should: Wear sterile attire Scrub in Use laser pointer Consider wearing long sleeve jacket or gown to decrease shedding Limit the number of observers to those who are essential to the case Limit movement and talking in OR suite during procedure Educate and require sign in prior to coming to OR All reps must complete mandatory Infection Control Education Wear hospital provided scrubs Perform hand hygiene prior to entry and as appropriate during case Don and wear mask appropriately LLF SSI Standards 2013

66 Handling of Equipment from Outside Company
Must be cleaned, inspected and sterilized by OR staff Staff should use appropriate lighting and magnification to inspect smaller pieces OR techs must inspect for cleanliness and residual debris after re-stocking by representative prior to sterilization Equipment must be brought to OR the day before surgery to assure appropriate handling No routine flash sterilization of company equipment LLF SSI Standards 2013

67 Safe Management of Fluids
Set up fluid basins using sterile technique Label all fluid basins with content and dose Change all fluids every 4 hours for longer procedures Use single use products /Single Patient Product vials must be maintained until the end of surgery as a patient safety measure Discard at end of case When in doubt - throw it out! Discard fluid from basin if any potential for contamination occurs LLF SSI Standards 2013

68 Maintain sterile fields and practices until site is completely closed
Do not start to break down tables and remove hoses, etc while suturing is being done LLF SSI Standards 2013

69 Operating Room - Patient Advocacy
Maintain watchful eye for any break in sterile technique Empower everyone to point out breaches Circulator should actively assist in observing practice and recognizing breaches Simulation of incidences will improve response during surgery Everyone is responsible for the patient’s safety! LLF SSI Standards 2013

70 Immediate-Use Steam Sterilization (IUSS)
Shortest possible time between a sterilized item’s removal from the sterilizer and its aseptic transfer to the sterile field Protect during transfer from contamination Use containers for transport-AORN recommendation Survey Readiness for Cleaning, Disinfection & Sterilization Do not store for future use Do not hold from one case to another LLF SSI Standards 2013

71 IUSS Recommendations, cont.
Follow same cleaning, decontamination and transport step as other processing Cleaning agents and brushes PPEs Water quality Follow manufacturer’s recommendations Monitor sterilization process including biological, chemical and others LLF SSI Standards 2013

72 IUSS Recommendations, cont
Implants must not be process by IUSS except in a documented emergency situation and no other option is available Only process devices and loads that have been validated with the specific cycle employed IUSS is not to be a substitute for adequate inventory LLF SSI Standards 2013

73 Survey Readiness for Cleaning, Disinfection & Sterilization
What do You Need to Know? Survey Readiness for Cleaning, Disinfection & Sterilization LLF SSI Standards 2013

74 Focus on Cleaning Practices
Manufacturer’s Instructions for Use (IFU) Up to date oneSource document site ( or 1-800= ) Available and used Staff competency for cleaning and decontamination based on IFUs Attention to detail for cleaning and rinsing Cleaning implements such as brushes, clothes, etc Discard or Re-use: be sure staff knows exactly how a brush should be handled Documentation of Training and Competency LLF SSI Standards 2013

75 Standardized Processes
Instruments cleaned and processed the same regardless of area (i.e. OR, CSS, etc) Loaner and other instruments handled identically Take apart rigid containers for cleaning NO SHORT CUTS LLF SSI Standards 2013

76 Sterilizer Biological Monitoring AAMI ST79
Test at least weekly, once a day better Test all types of loads Rigid containers Protective case Surgical wrap Hint- since each configuration must be tested it is wise to limit the number of configurations Temperature/Pressure Gravity and Dynamic Air Removal LLF SSI Standards 2013

77 Implants Test all cycles with implant Traceability of Implants
BI, Class 5 Integrator Do not release until biological result is available Policy for early release Multidisciplinary Input Who can determine it? Surgeon OR Administration Define emergency exceptions Traceability of Implants LLF SSI Standards 2013

78 IUSS Monitoring Place BI on bottom shelf over drain
Use a Class 5 indicator as an internal chemical indicator Physical Monitors Document - who started and then who removed item from sterilizer Reconcile with patient information Review all data by experienced person Do not use if any data suggests a failure LLF SSI Standards 2013

79 Loaner Policy Know Contents and Manufacturer’s IFU
Detailed inventory of contents FDA clearance Adequate time for cleaning, decontamination and sterilization prior to procedure Maintain records Identify responsibility of surgeon, OR staff, sterile processing area and sales rep Loaner Checklist Communication is Key LLF SSI Standards 2013

80 CMS Mandatory Reporting for Surgical Cases 2012
Hospitals must report SSI surveillance data for COLO and HYST via NHSN to avoid a reduction of 2.0 percent in their Medicare Annual Payment Update CMS Mandatory Reporting for Surgical Cases 2012 Centers for Medicare and Medicaid Inpatient Prospective Payment System LLF SSI Standards 2013

81 In Patient NHSN Operative Procedure Categories
COLO: Incision, resection or anastamosis of the large intestine; includes large-to-small and small-to-large bowel anastamosis; excludes rectal repairs* HYST: Removal of uterus through the abdomen* (includes laparoscopic) * General descriptions only; follow ICD-9-CM list LLF SSI Standards 2013

82 SSI Requirements Facilities must observe NHSN SSI protocol in entirety
NHSN will submit a subset of data to CMS: – >18 years of age – Inpatients – Deep incisional and/or organ/space SSI – Identified on admission or readmission LLF SSI Standards 2013

83 NHSN Website Key Resources
LLF SSI Standards 2013

84 Tenets of Surveillance
Surveillance versus Clinical Definitions Different purposes – May not agree –Comments section useful to note important factors Can submit questions to NHSN mailbox LLF SSI Standards 2013

85 Tenets of Surveillance
Consistency is a Must! Criteria designed to look at a population at risk Identify patients meeting the criteria Consistently apply the criteria Ensures the comparability of the data- protects your facility and others LLF SSI Standards 2013

86 NHSN Requirements for Surveillance
Active Patient-based not culture-based Prospective Requires that a variety of sources for case finding be utilized: Culture results Nursing unit rounds; kardexes, wound care and ID consults, temperature logs, etc. Staff notification Readmissions LLF SSI Standards 2013

87 Definitions SSI OR Implants Emergency Endoscope
Superficial Incisional SSI (primary or secondary) Deep Incisional SSI Organ/Space SSI OR Implants Emergency Endoscope LLF SSI Standards 2013

88 SSI Definitions CDC/NNIS/NHSN Types
Superficial incisional (involving only skin or subcutaneous tissue of the incision) Deep incisional (involving fascia and/or muscular layers) Organ/space LLF SSI Standards 2013

89 NHSN Risk Factors Patient Risk Factors Hospital Factor Level
General anesthesia Age Wound class Emergency Gender ASA score Trauma Endoscope Duration of procedure Bed size Med School Affiliation LLF SSI Standards 2013

90 Risk Models LLF SSI Standards 2013

91 Standard Infection Ratio (SIR)
Based on Standardized Mortality Ratio (SMR) Used extensively in public health research Compares the experience in one facility to that in a standard population Advantage: Presents in single metric how the number of infections experienced relates to the expected number Number Observed/Number Expected LLF SSI Standards 2013

92 COMPUTING THE SIR Numerator: Simply the number of infections at that facility during time period Denominator: Multiply the referent stratum-specific rates by the number of patients in each stratum Sum all of these Equals the “expected denominator” LLF SSI Standards 2013

93 What does a SIR mean? An SIR of “1” signifies that the observed and expected numbers of HAI are the same when compared to like locations in NHSN An SIR of > “1” signifies that there were more observed HAIs CAUTIs than expected when compared to like locations in NHSN. i.e., SIR= 1.50 = 50% more Infections An SIR of < “1” signifies that there were fewer observed HAIs than expected when compared to like locations in NHSN. i,e, SIR=0.50 = 50% fewer infections LLF SSI Standards 2013

94 Accurate Denominator Data Is Critical
Surgery completed in a single trip to the OR Incision closed before leaving OR Surgery conducted in defined operating room suite May be an in- or out-patient procedure (based on monthly reporting plan) Laparoscopic & traditional approaches included LLF SSI Standards 2013

95 Operative Characteristics SCIP Antimicrobial prophylaxis
Administer antimicrobial prophylaxis only when indicated A-I Timing Administer within 1 hour before incision to maximize tissue concentration A-I Vancomycin and fluoroquinolones can be given 2 hours before incision. Choice Select appropriate agent on basis of surgical procedure, most common pathogens causing SSI for a procedure, and published recommendations. A-I Duration of Therapy Stop prophylaxis within 24 hours after the procedure for all procedures, except cardiac surgery; for cardiac surgery, antimicrobial prophylaxis should be stopped within 48 hours. A-I LLF SSI Standards 2013

96 Do not use these strategies routinely to prevent SSIs
Do not routinely use vancomycin for antimicrobial prophylaxis; vancomycin can, however, be an appropriate agent for specific clinical circumstances (B-II). Reason for use must be documented Does not cover gram negative bacteria 2. Do not routinely delay surgery to provide parenteral nutrition (A-I). LLF SSI Standards 2013

97 SSI Prevention Measures
4. Measure and provide feedback to providers on the rates of compliance with process measures, including antimicrobial prophylaxis, proper hair removal, and glucose control (for cardiac surgery) (A-III). 5. Implement policies and practices aimed at reducing the risk of SSI that meet regulatory and accreditation requirements and that are aligned with evidence-based standards (eg, Centers for Disease Control and Prevention and professional organization guidelines) (A-II). LLF SSI Standards 2013

98 SSI Prevention Education
Educate surgeons and perioperative personnel about SSI prevention (A-III). Teach strategies aimed at minimizing perioperative SSI risk through implementation of recommended process measures. Provide education regarding the outcomes associated with SSI, risks for SSI, and methods to reduce risk to all patients, patients’ families, surgeons, and perioperative personnel. Local epidemiology including MDROs includingMRSA Basic prevention strategies LLF SSI Standards 2013

99 SSI Prevention Education
Educate patients and their families about SSI prevention, as appropriate (A-III). Provide instructions and information to patients before surgery, describing strategies for reducing SSI risk. Specifically provide preprinted materials to patients in accordance with evidence-based standards and guidelines LLF SSI Standards 2013

100 Patient Safety Handout
Points Discussed / Questions asked in Handout: -Will I receive and antibiotic prior to surgery? -Should I take a shower with antibacterial soap prior to surgery? Infection Control Tips: -Keep your hands clean -Do not hesitate to ask your healthcare provider if he/she has washed their hands -Cover your mouth and nose when you cough or sneeze. Discard the tissue and then clean your hands -Safely care for wounds and catheters by learning proper aseptic or clean techniques -Handle needles and other sharp items safely and discard into a sharps container to prevent injury to you and others LLF SSI Standards 2013

101 Patient Education LLF SSI Standards 2013

102 Web Pages and Materials for Patients
JAMA patient page: wound infections (from the Journal of the American Medical Association; available at: Surgical Care Improvement Project consumer info sheet (available at: What you need to know about infections after surgery: a fact sheet for patients and their family members (available at: LLF SSI Standards 2013

103 IHI SSI Prevention Bundle
Appropriate use of antibiotics Appropriate hair removal Maintenance of post operative glucose for major cardiac surgical patients Post operative normothermia for colorectal surgery patients LLF SSI Standards 2013

104 Checklists in OR Improve Performance
When checklists were available to surgical teams, they missed just 6 percent of life­saving steps, compared with 23 percent when the tool was not available, according to results published online Wednesday in the New England Journal of Medicine. January 2013 LLF SSI Standards 2013

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111 Current Issues Preoperative bathing with chlorhexidine-containing products Not conclusive Other processes in study Impregnated wipes Regular or foam CHG direct application Routine bed bath with CHG To gain the maximum antiseptic effect of chlorhexidine, it must be allowed to dry completely and not be washed off. Studies do show reduction in skin flora and some also correlate now to reduction in SSI Patient Compliance Did they do it? Did they reach critical areas? LLF SSI Standards 2013

112 Current Issues Routine screening for MRSA or routine attempts to decolonize surgical patients with an anti-staphylococcal agent in the preoperative setting Timing Opportunity Mupirocin in specific patient groups undergoing orthopedic or cardiac surgery may be effective Not randomized controlled trials. Preoperative intranasal and pharyngeal chlorhexidine treatment for patients undergoing cardiothoracic procedures Although data exist from a randomized, controlled trial to support its usage, chlorhexidine nasal cream is neither approved by the US Food and Drug Administration nor commercially available in the United States. LLF SSI Standards 2013

113 Do the new Antimicrobial Products reduce SSIs?
Product Types Future Needs Sutures Dressings Skin Preps or Cleansers Wipes Other forms Intra operative Irrigation Products Industry sponsored Multi-center trials needed Independent studies with enough cases Value Analysis LLF SSI Standards 2013

114 Patient Preoperative Shower Packet
Packet given in the clinics or during preop testing -Instruction sheet -Patient Safety Handout -Packet or container with CHG product Other areas for pre-operative showering: -Pre-op Admissions or Pre-Op Holding Area -Pre-admission on a floor or ICU Documentation of pre-operative showering: -Pre-op nursing notes in holding area -Clinic notes -Transplant coordinator notes -Unit nurse who assisted with bath LLF SSI Standards 2013

115 CHG Showering Info Bathing 2 times with CHG (once the evening before
Preoperative shower or bath with CHG reduces skin microbial counts more effectively than povidone-iodine or other antimicrobial soaps Bathing 2 times with CHG (once the evening before & then the morning of ) is recommended to increase effectiveness. New IHI Ortho recommends showering x3 days Daily bathing with CHG has been shown to reduce Catheter Line Associated Bacteremias, MRSA, and C. difficile. Initially, pre-operative showering with an antimicrobial agent has been shown to reduce infection risk especially in the cardiac surgery patient. The practice was quickly adopted by orthopedics with the same success. Because the practice has been so successful in these groups, the national trend for many surgical procedures is to recommend preoperative showering with a chlorhexidine gluconate (CHG) product. Once again, this key process presents challenges to healthcare providers. Those challenges include but are not limited to: 1. Providing CHG to the patient in the pre-operative visit to prior to surgery to facilitate showering the night before and the morning of surgery. 2. Educating the patient on proper showering techniques 3. Properly documenting the education of the patient. 4. Providing pre-operative showers to the in-patient prior to surgery or a bed bath if patient is bedridden, 5. Documenting the showering process in the patients record. DO NOT INCLUDE ENT PATIENTS IN THE PREOP SHOWERING PROGRAM WITHOUT PRIOR VERIFICATION FROM THE ATTENDING PHYSICIAN. LLF SSI Standards 2013

116 Pre-Operative Showering & No Shaving
for the Prevention of Surgical Site Infections Tips for SSI Prevention: Showering with CHG soap both the night before and morning surgery Shaving is no longer recommended unless ordered specifically by the physician Why Pre-op Shower, you ask? To reduce normal skin flora at the surgical site and minimize the risk of developing infections. Also, by not shaving any areas, you keep the skin intact and reduce micro tears that could become sources of infection. What do I tell the patient to do: Shower both the night before and the morning of the surgery Use the CHG soap provided at time of the clinic visit Do not shave any areas of the body within 48 hours prior to surgery Scrub body from head to toe avoiding mucous membranes, eyes, ears, etc. Dry off with clean dry towel What do I Give to the Patient: Written instructions and information sheet CHG soap (approximately 30 ccs) How do I document this information: Please note in the progress / clinic note that info and product was given If in Pre-Op area, please note on peri-operative form if pt showered in pm and am Questions: Please call Infection Control Thank you for your participation in this initiative to reduce Surgical Site Infections. LLF SSI Standards 2013

117 Preoperative Chlorhexidine Bathing Instructions
Once the decision to have surgery has been made, there are a few steps you can take to reduce your risk of acquiring an infection at the surgical site. Your skin is not sterile and contains germs that are present everyday. We are able to live with these germs because of our skin barrier. Once the barrier is broken, for example, with a surgical incision, you become more vulnerable to these germs. In an effort to protect yourself from these germs, a preoperative shower with a special soap is recommended. This soap contains a substance called chlorhexidine gluconate (CHG)* and helps to reduce the numbers of bacteria on your skin. This soap will be given to you or it may be purchased at a local drug store. (Call ahead and ask if it is in stock). *Not to be used by people with known allergies to chlorhexidine. If an allergic reaction occurs, call you doctor immediately. Soap is for topical use only; DO NOT DRINK Bathing Instructions: Shower or bathe with CHG both the night before and the morning of your surgery. Do NOT shave any body area. Wash your hair in the usual fashion with your own shampoo and rinse your hair and body thoroughly. From the neck down, apply the CHG to your entire body paying close attention to the area where your surgery will be performed. (DO NOT put the CHG near your face, eyes, or ears as it can cause permanent damage). Turn the water off to prevent rinsing prematurely and continue to lather and wash your body for 5 minutes. Do NOT scrub your skin too hard as you wash and do not wash your body with regular soap after the CHG. Turn the water back on and rinse thoroughly, then pat yourself dry with a clean, fresh towel. Pay particular attention to the circled areas LLF SSI Standards 2013

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 SCIP Inf-4 - Cardiac Surgery Patients With Controlled 6 A.M. Postoperative Blood Glucose SCIP Inf-6 - Surgery Patients with Appropriate Hair Removal SCIP Inf-9 - Urinary catheter removed on Postoperative Day 1 (POD 1) or Postoperative Day 2 (POD 2) with day of surgery being day zero SCIP Inf-10 - Surgery Patients with Perioperative Temperature Management LLF SSI Standards 2013

119 SCIP-1 Timing LLF SSI Standards 2013

120 Improvement Strategies
Incorporated into OR Checklist Letters to team members with timing failures Review by SCIP committee to all noting how many days since failure by OR location Culture Change – self reporting of failures Antimicrobial Team – Selection education and interventions LLF SSI Standards 2013

121 Infection Prevention Communication
Where Each Surgical Service Patient Care Units for CA-UTI prevention C-Suite Infection Prevention & Control Committee Service/Unit Departmental Meetings Quality Safety Evaluation Committee SCIP Team Board Quality When Quarterly Daily for CA-UTI Other What Quarterly Service Specific SSI Rate Trending + Recommendations CA-UTI Prevention by Units LLF SSI Standards 2013

122 LLF SSI Standards 2013

123 Strategies of the Neurosurgery Infection Prevention Team
Employed Adverse Event Trigger Strategy Every Monday IPC notified NSG Chair of potential cases Investigation and Data Collection related to procedure and team members NSG Team reported infections to IP Each case reviewed with all participants at meeting 2x’s a month Root Cause Analysis discussion concerning each case was done Evaluation of Practice, including surgical and unit procedures and OR setting OR observational studies performed by IP with feedback to team and staff Education – every meeting addressed a “hot topic” Development of Checklist LLF SSI Standards 2013

124 Surveillance & Data Trending
SSIs detected through reporting of infections from the NSG Team as well as by routine surveillance methodology used by the IPC Department. Class I SSI and procedure-specific SSI rates were calculated on a quarterly basis. Reported to IPC Committee, NSG team, Surgical Committee and Operations Committee of the Medical Staff and through the quality committee structure. LLF SSI Standards 2013

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126 Process & Practice Improvements
Improved classification with implementation of a mandatory classification field Developed & implemented checklist and improved consistency in following recommended practices MRSA screening has identified about 8% of their elective surgical patients are MRSA positive. Noted that more patients had infections with MSSA NSG staff screened for MRSA/MSSA- no MRSA isolated, 4 MSSA identified and decolonized. No linkage to cases. Implemented pre-op screening for MRSA/MSSA and decolonization LLF SSI Standards 2013

127 Process & Practice Improvements
Improved consistency of Pre-op Showering with CHG Improved Management of medications, vials and fluids Created signage to make sure vial tops were scrubbed with alcohol before each entry Improving OR environment (new carts, more storage, on-going monitoring by 2 OR patient safety nurses, no personal items in the OR room) NSG to report infections to IP LLF SSI Standards 2013

128 Process & Practice Improvements
Education for Anesthesiology, OR team and Patient Care Unit staff Pre-Op Antibiotics (ABX) Prophylaxis Changed ABX prophylaxis to Kefzol from Vancomycin based on literature review, if Vancomycin is used Kefzol is still needed, unless allergic DC ABX at 24 hours according to SCIP LLF SSI Standards 2013

129 STOMP: Stamp Out MRSA/MSSA Project

130 References CDC Prevention of Surgical Site Infections, 1999
Altemeir WA, Burke JF, Pruitt, BA, Sandusky,WR and the American College of Surgeons, Committee on Control of Surgical Infections of the Committee on Pre-and Postoperative Care. Manual on Control of Infection in Surgical Patients.Second Edition. JB Lippincott Company. Philadelphia Janelle J, Howard, RJ, and Fry D. Chapter 23 Surgical Site Infections. APIC Text of Infection Control and Epidemiology, 2nd Edition, 2005. Mangram AJ, Horan TC, Person ML, Silver LC, Jarvis WR. The Hospital Infection Control Practices Advisory Committee. Guideline for prevention of surgical site infection. Infection Control and Hospital Epidemiology 1999;20: LeFrock, SHEA Annual Meeting, Philadelphia, 2004. Bratzler, DW. Surgical Infection Prevention and Surgical Care Improvement: National Initiatives to Improve Care for Medicare Patients. Yokoe DS, Mermel LA, Anderson DJ, Arias KM, Burstin H, et. al. Compendium of Strategies to prevent HAIS. Infection Control and Hospital Epidemiology October 2008, Vol. 29, supplement 1 World Health Organization IHI Surgical Site Infection (SSI) Reporting Through NHSN: Tips, Trips and Best Practices . Kathy Allen-Bridson. Nurse Consultant , Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention , November, 2011, Webinar LLF SSI Standards 2013

131 Resources 1. Klevens R.M., Edwards JR, Richards CL Jr., et al. (2007) Estimating health care-associated infections and deaths in U.S. hospitals, Public Health Rep. 2007;122(2): de Lissovoy G, Fraeman K, Hutchins V, et al. (2009) Surgical site infection: incidence and impact on hospital utilization and treatment costs. Am J Infect Control. 2009;37(5): Five Million Lives Campaign. (2008) Getting Started Kit: Prevent Surgical Site Infections How-to Guide. Cambridge, MA: Institute for Healthcare Improvement; 2 LLF SSI Standards 2013

132 References AAMI AORN Perioperative Standards and Recommended Practices
Use Statement.pdf AORN Perioperative Standards and Recommended Practices Recommended Practices for Sterilization in Perioperative Setting Recommended Practices for Cleaning and Care of Surgical Instruments and Powered Equipment Recommended Practices for Surgical Attire Centers for Medicare & Medicaid Services Ambulatory Surgical Center Survey LLF SSI Standards 2013

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