1. Prevention of Surgical Site Infections (SSI)
MSIPC Fundamentals of Infection Prevention & Control
October 2014
Karen Hoover, RN
Infection Prevention Coordinator
St. Mary’s of Michigan, Saginaw

2. SSI: A Complication of Surgical Care
> 51.4 million surgical procedures/year in US
31% of all HAI’s due to SSI, second only to UTI
> 91,000 readmissions for SSI Rx
1 million additional inpatient days
1.6 billion excess costs
Associated mortality rate of 3%
Cost… Pay for performance …patient safety
CDC’s Guideline for Prevention of Surgical Site Infection,
Jan 2014 CDC
Coding in past

3. Common surgical/Procedures
719,000/year Total knee
498, hysters
395, CABG
332, Total Hip
Ambulatory
1.3 million cataracts
923,000 Lens implants
779,000 Endoscopies
735,000 Injections of spine
Approx. 40% have more than 1 procedure
CDC

4. Risk Factors for SSI: identification & opportunities for intervention
Risk factor: variable with significant, independent association with development of SSI
Patient: age, nutrition, diabetes, smoking, obesity, immunocompromised, pre-op LOS, micro-flora, other infection
SSI prevention measure: action(s) to reduce SSI risk, antibiotic prophylaxis, skin prep/antisepsis
Operation: …patient & peri-op personnel, duration, antibiotic redosing,, surgical asepsis, traffic flow, surgical technique (robotic), hair removal, immediate use sterilization
Environmental: cleaning, disinfectant contact time, UV light, OR environment-HVAC
Risk of SSI after receipt of blood products 3.5%
- increasing age independently predicted an increased risk of SSI until age 65 years,
- degree of microbial contamination of the OR air is directly proportional to the number of people in the room
- wounds should be kept clean by covering with a sterile dressing for 24 to 48 hours after surgery

5. Principles for Prevention of SSI
Minimize access of bacteria to the surgical site
Measures to neutralize that do gain access to site
Reduce that which is conducive to infection
Enhance the host defenses - look at risk factors
Follow established guidelines

6. Pathogenesis of Surgical Site Infection (SSI)
Dose x virulence
Resistance of Host
= risk of SSI
> 105 / gm tissue risk; with foreign body only 100/gm is needed to cause SSI
Pathogens:
Endogenous – flora normally contained
Exogenous – healthcare personnel, environment, devices/materials used
Twenty percent of bacterial skin flora resides in skin appendages, such as sebaceous glands, hair follicles, and
sweat glands.

7. Key Concepts on Source of SSI Pathogen: OR personnel or patient?
Every surgical site has bacteria by the end of the procedure!
Four Clinical variables determine infection:
Inoculum of bacteria
Virulence of bacteria
Microenvironment
Host defenses
Endogenous – flora normally contained

8. Distribution of Pathogens Causing SSIs
Mangram AJ. AJIC 1999;27:97-134

9. Risk Classification for SSI:
CLASS I/CLEAN WOUNDS--an uninfected surgical wound in which no inflammation is encountered and the respiratory, alimentary, genital, or uninfected urinary tracts are not entered.
CLASS II/CLEAN-CONTAMINATED WOUNDS--a surgical wound in which the respiratory, alimentary, genital, or urinary tracts are entered under controlled conditions and without unusual contamination.
CLASS III/CONTAMINATED WOUNDS--open, fresh, accidental wounds. In addition, surgical procedures in which a major break in sterile technique occurs (eg, open cardiac massage) or there is gross spillage from the gastrointestinal tract and incisions in which acute, nonpurulent inflammation is encountered are included in this category.
primarily closed and, if necessary, drained with closed drainage. Surgical wound incisions that are made after nonpenetrating (ie, blunt) trauma should be included in this category if they meet the criteria. Specifically, surgical procedures involving the biliary tract, appendix, vagina, and oropharynx are included in this category, provided no evidence of infection is encountered and no major break in technique occurs.

10. Smoking & Surgery: Bad combination
Randomized, controlled trial: 48 smokers(S) vs 30 never smoked (NS)
228 wounds evaluated
SSI rate 12% S vs 2 % in NS
SSI rate significantly less for S if abstain for 4wks (27% vs.1.1%)
Wound rupture: 12% S vs. 0% NS
When to stop … 30 days?
2-6months?
Sorensen LT. Ann Surg 2003;238:1-5

11. Preoperative Patient Shower with Antimicrobial Soap
Bacterial counts on skin are 9-fold lower after shower - chlorhexidine
CDC SSI Guidelines: Require patients to bathe with antiseptic on at least the night before their operation
CHG cloth use night before & day of surgery

12. Intranasal Mupirocin & Prevention of SSI
Orthopedic & cardiothoracic patients - significant reduction in SSI among treated1-3
However these were retrospective & used historical controls
Another randomized trial in ortho.surg found less S. aureus nasal carriage but no signif. Reduction in SSI rate4
1. Kluytmans JAJW. ICHE 1996;
17:780-5.
2. Cimochowski GE. Ann Thorac
Surg 2001;71:
3. Wilcox MH. J Hosp Infect 2003;
54(3):
4. Kalmeijer MD. Clin Infect Dis
2002;35:353

13. Preventing Surgical Site Infection: System-level success
[Usry GH, et al. AJIC 2002;30:434-6.]
Intervention:
Intranasal mupirocin
48 hrs prior to through 5 days post op
Results:
94% of patients Rx
Rate of SSI dropped by: 53% overall
55% for deep sternal
Rate
Per
100
CABGs

14. Surgical Care Improvement Project (SCIP)
Antibiotic Timing - <60min
Antibiotic Selection – type/body location
of procedure
- dosing for body wt.
- duration of procedure
- PCN allergy?
- cost of antibiotic
2006
Ancef
Vancomycin or Clindamycin

15. Surgical Care Improvement Project (SCIP)
within 24 hours surgery end time
(SStop ATB 24 Hours end time 48 for Cardiac Surgery
Blood sugar <200 at 6 am POD 1 & 2
S < 200 by 6STTTTTTGKLBLK a.m. POD 1 & 2 forAppropriate Hair removal …no razors
DVT Prophylaxis
Beta-blocker given before OR and after unless contraindicated
DVTeICD (Int. Compression Device), TED’s, Heparin, Warfarin
Foley cath …remove by POD 2 or physician note why not
implementing an intravenous insulin regimen to maintain postoperative glucose levels lesser than 200 mg/dL for the first 48 hours after surgery

16. Centers for Medicare & Medicaid Services (CMS) Actions
Payment reforms for inpatient hospital services in 2008:
…ensure that Medicare no longer pays for the additional costs of certain preventable conditions (including certain infections) acquired in the hospital…
1) Serious preventable events: Object left in during surgery; air embolism; Delivering ABO-incompatible blood or blood products
2) catheter-associated urinary tract infections
3) pressure ulcers
4) Vascular catheter associated infection
5) Mediastinitis after CABG surgery
6) Patient falls
7) VAE
8) Influenza vaccination rates
9) Future: MRSA, S. aureus BSI, CDAD (C. diff)

17. Impact of SSI Occurring After Discharge
* Many/Most SSI not identified until after discharge
Cost for care with SSI were 2.9 times greater
23% of readmits & 18% of ER visit …some at other facilities
Post discharge SSIs can impair physical & mental health
Surveillance (PDS) is inconsistent …phone/paper …honest
Education - ? enough/consistent/updated
Host defense – acute and chronic medical conditions
Effective management to minimize consequences
Example of GG, G & Mom with hyster LOS

18. . ICD – 9 – CM codes Stitch/ Superficial Deep Pt. DOB Surg Class Room
Procedure Description
Staple
Incisional J
5/22/63
3/7 1
OR 12
DECOMPRESSIVE LAMINECTOMY L4-5, L5-S1, NEURO FORAMOTOMY L4-5, L5-S1
4/8/54
KNEE ARTHROSCOPY LEFT
7/29/59
3/30
KNEE ARTHROSCOPY RIGHT, PARTIAL MENISCECTOMY,
6/20/62
3/14
KNEE ARTHROSCOPY LEFT, PARTIAL MENISECTOMY, PARTIAL CHONDROPLASTY
11/19/68
3/21
KNEE ARTHROSCOPY RIGHT, PARTIAL CHONDROPLASTY, RELEASE PLICA
1/28/32
3/28
KNEE TOTAL ARTHROPLASTY LEFT
8/31/91
left KNEE ARTHROSCOPY with fixation of osteochondyle fx, debridement of
8/18/40
LEFT TOTAL HIP REPLACEMENT
9/10/30
3/11
OR 10
OPEN REDUCTION, PINNING RIGHT FEMORAL NECK
1/29/05
3/15
OR 8
REALINEMENT WITH PINNING AND CASTING LEFT ELBOW
9/16/60
RELEASE OF ACHILLES TENDON RIGHT
2/24/32
REMOVAL OF FOREIGN BODY RIGHT THIGH ANTIBIOTIC BEADS
5/14/59
REVISION LEFT TOTAL KNEE ARTHROPLASTY, EXTENSIVE SYNOVECTOMY
11/1/44
REVISION, POLY LEFT KNEE, DEBRIDMENT, LATERAL RELEASE
1/13/25
RIGHT KNEE ARTHROSCOPY, CHONDROPLASTY, PARTIAL MENISCECTOMY
12/1/38
RIGHT OPEN QUADRICEPS REPAIR WITH AFLEX GRAFT
Stitch/staple:
minimal inflammation and discharge confined to the points of suture penetration
Superficial Incisional:
Purlent drainage from the superficial incision; or pain or tenderness, localized swelling, redness, or
heat, and superficial incision is deliberately opened by surgeon, and is culture-positive or not cultured
If from secondary incison (e.g., donor site [leg] incision for CABG), please note: Y- SIS
Deep incisional :
a. purulent drainage from the deep incision but not from the organ/space
b. incision spontaneously dehisces or is deliberately opened by a surgeon and is culture-positive or not cultured
during reoperation, or by histopathologic or radiologic examination .
ICD – 9 – CM codes

19. The Challenge of Surveillance of SSIs: expanding universe of health care delivery
Major trend towards delivery in wide range of settings
Short lengths of stay + inter-facility transfer is common
Networking!

20. Ambulatory Surgery: Risk Free?
Cluster of Endoph-thalmitis after cataract surg.
Acremonium kiliense
4 patients
Risk Factor (RF): 1st case, Mondays
Humidified air in ventilation likely source
Fridkin SK. Clin Infect Dis 1996;
Steroid Injection Outbreak
Cluster of fungal contamination of saline breast implant
Saline bottle stored under water-damaged ceiling &
OR in negative pressure
Kainer MA. 40th IDSA (abstr)

21. CMS for Ambulatory Care
42 CFR Part 416 Medicare and Medicaid Programs; Ambulatory Surgical Centers (ASC), Conditions for Coverage:
…require the ASC to designate a qualified professional, such as a registered nurse, as the infection control officer
The infection control condition places accountability on ASCs to prevent, control, and
investigate infections and communicable diseases, and take action that result in improvements…

22. Waterless Alcohol-based Hand Rub for Surgical Hand Antisepsis
Randomized trial, 4387 pts.
Hand rub vs scrub with antimicrobial soap + water
SSI rate in hand rub (2.4%) vs scrub (2.5%) not signif.
Better compliance, less skin irritation/dryness with hand rub in personnel
Current stocks of smallpox vaccine were produce from another live virus (vaccinia virus) that promotes an immune response to smallpox virus without risk of infection. The unique method of vaccine delivery involves utilization of a bifurcated needle for scarification and inoculation. A scar after vaccine administration has been used as evidence of successful immunization.
This vaccine does NOT provide life-long immunity.
Parienti JJ. JAMA 2002;
288:722-77
WHO

23. Possible SSI Prevention Measures
Subcuticular suturing vs skin stapling technique, CABG - 2 studies; no consistent results (Mullen JC. Can J Cardiol 1999;15:65- ; Chughtai T. Can J Cardiol 2000;16:1403-)
Quill Suturing? …expensive
Anemia & leukocyte-depleted red blood cell transfusion - studies have had mixed results; more study needed(Jensen LS. Transfusion 1995;35:719-; Titlestad IL. Int J Colorectal Dis 2001;16:147-;van de Watering LM. Circulation 1998;97:562-)
Laminar Airflow & Orthopedic Surgery - Mixed results & difficult to demonstrate clear cost effectiveness (Berbari EF. Clin Infect Dis 1998;27:1247-)

24. Possible SSI Prevention Measures
Supplemental perioperative oxygen- randomized trial found lower SSI with 80% O2 among 500 colorectal surgery pts.;however-high SSI rate & risk index in control population - Need confirmation (Grief R. N Engl J Med 2000;342:161-7)
Periop. normothermia - randomized trial of 200 patients, colorectal surgery pts. = lower SSI rate with additional warming(forced air + IV fluids) vs those with regular care; more investigation needed for wider application (Kurz A. N Engl J Med 1996;334: )

25. Category IA SSI Prevention Recommendations
Patient-focus:
treat existing infections first before OR
avoid hair removal but if needed use clippers
Asepsis & technique:
aseptic principles: IV, inserting catheters, administering medications
AJIC 1999;27:97-132

26. Category IB SSI Prevention Recommendations
Patient-focus:
control serum blood glucose
encourage tobacco cessation
preop shower
clean skin incision site + apply antiseptics
Surgical Team:
no artificial nails
surgical hand antisepsis
AJIC 1999;27:97-132

27. Category IB SSI Prevention Recommendations
Intraoperative:
Positive pressure in OR
Min. 15 air changes/hour
Filter supply air
Keep OR doors closed as much as possible
sterilize surgical instruments; limit flash sterilization
Surgical Team:
surgical mask, hair cover
gown & sterile gloves
Gentle handling of tissue
AJIC 1999;27:97-132

28. Category IB SSI Prevention Recommendations
Surveillance:
Use CDC definitions
Apply risk index
Periodically calculate risk stratified SSI rates
Report SSI rates to surgical personnel
Use standard case finding methods
AJIC 1999;27:97-132

29. Surgical Site Infection Criteria
Superficial incisional SSI
Infection occurs within 30 days after any NHSN operative procedure and
involves only skin and subcutaneous tissue of the incision and
patient has at least one of the following:
a. purulent drainage from the superficial incision.
b. organisms isolated from an aseptically-obtained culture of fluid or tissue from the superficial incision.
c. superficial incision that is deliberately opened by a surgeon and is culture-positive or not cultured
and patient has at least one of the following signs or symptoms: pain or tenderness; localized swelling;
redness; or heat. A culture negative finding does not meet this criterion.
d. diagnosis of a superficial incisional SSI by the surgeon or attending
physician or other designee (see reporting instructions).

30. Two specific types of superficial incisional SSIs
Superficial Incisional Primary (SIP)
superficial incisional SSI that is identified in the primary incision in a patient that
has had an operation with one or more incisions
(e.g., C-section incision or chest incision for CABG)
Superficial Incisional Secondary (SIS)
superficial incisional SSI that is identified in the secondary incision in a
patient that has had an operation with more than one incision
(e.g., donor site incision for CBGB)
Do not report a stitch abscess, stab wound or pin site infection as SSI
Diagnosis of “cellulitis”, by itself, does not meet criterion d for superficial incisional SSI.

31. Deep incisional SSI
Infection occurs within 30 or 90 days after the NHSN operative procedure and
involves deep soft tissues of the incision (e.g., fascial and muscle layers) and
patient has at least one of the following:
a. purulent drainage from the deep incision.
b. a deep incision that spontaneously dehisces or is deliberately
opened by a surgeon and is culture-positive or not cultured
and patient has at least one of the following S/S:
fever (>38°C); localized pain or tenderness.
c. an abscess or other evidence of infection involving the deep
incision
d. diagnosis of a deep incisional SSI by a surgeon
or attending physician or other designee

32. Organ/Space SSI
Infection occurs within 30 or 90 days after the NHSN operative procedure and
infection involves any part of the body, excluding the skin incision, fascia, or muscle layers, that is opened or manipulated during the operative procedure and
patient has at least one of the following:
a. purulent drainage from a drain that is placed into the organ/space
b. organisms isolated from an aseptically-obtained culture of
fluid or tissue in the organ/space
c. an abscess or other evidence of infection involving the
organ/space

33. Special Comments:
Occasionally an organ/space infection drains through the incision and is considered a complication of the incision. Therefore, classify it as a deep incisional SSI.
• Report mediastinitis following cardiac surgery that is accompanied
byosteomyelitis as SSI-MED rather than SSI-BONE.
• If meningitis (MEN) and a brain abscess (IC) are present together
after operation, report as SSI-IC.
• Report CSF shunt infection as SSI-MEN if it occurs within 90 days
of placement; if later or after manipulation/access, it is
considered CNS-MEN
Report spinal abscess with meningitis as SSI-MEN following spinal
surgery.

34. Environmental Infection Control Guidelines, 2003
HVAC:
Positive pressure ventilation
Filtration
Environmental Cleaning
Preventing water-associated illness
Preventive maintenance
MMWR 2003;52:RR-10

35. A Surgeon’s Perspective on Prevention of SSI
“The most critical factors in the prevention of postoperative infections, although difficult to quantify, are the sound judgment and proper technique of the surgeon and surgical team, as well as the general health and disease state of the patient”
-Nichols RL. Emerg Infect Dis 2001;7(No.2):220-4.

36. How to Display SSI data:
Target …state in IP Plan
Just %? …what if 1 of 2 procedures develop SSI?
Denominator & numerator?
Graphs
Previous year …2 years?
Scorecards
Compare with NNIS vs Standard Infection Ratio (SIR)
Special Investigations
High volume surgery
Surgeon specific?
“Tell them/show them what they need to see”

37. Sample of displaying SSI’s
CABG 1 3
# done 17 8 24 13 15 19 14 25
194 16 11
SSI rate/month
7.7%
5.3%
7.1%
1.5%
6.3%
9.1%
Cardiac other 7 5 6 4 2 52
33.3%
12.5%
25.0%
5.8%
Colon 10 9 12 18
148
20.0%
14.3%
22.2%
16.7%
5.6%
8.0%
6.8%
5.9%
Last Updated 9/17/2010, 11/1/2010, 1/17/2011

38. Post discharge Data Surveillance:
Patient Name
DOB
Surgery
Class
Room
Procedure Description
Name of hospital
_________________
Education: New surgeons/Annually (definitions)
Skin/staple related? …don’t count
Incisional … skin or sub-Q , drainage, dehisence, I&D
Any cultures?
Readmit? Within 30 days vs NEW 2013: 90 days (implants)

39. SSI Surveillance & Prevention Intervention
Feedback: surgeon/surgical personnel or committee (s)
Result: Overall SSI rate/SIR for given (targeted) surgeries
Action Plan: Quality Improvement – education, equipment, timing, etc.

40. Summary Aspects of Surveillance Program for Prevention of SSIs
SSIs cause considerable morbidity and mortality and are expensive complications to treat - prevention therefore is cost effective
Surveillance & Interventional Epidemiology is an effective component of a facility’s patient safety/performance improvement program
Feedback of process & outcome data is helpful but broad partnership involving multiple disciplines is likely key to success

41. Skin & Soft Tissue Infections
Changing Pattern of Community- Associated Skin and Soft-Tissue Infection with methicillin-Resistant Staphylococcus aureus (CA-MRSA)
Almost three quarters of the soft-tissue infections were caused by CA-MRSA (N=389 patients)
King MD, et al. Ann Intern Med 2006; 144:

42. Conclusions: SSI’s will always be with us MDRO’s will challenge us
New techniques and technology will evolve
Government agencies will change how we measure quality performance
Reimbursement can effect our process, advancing to new equipment or products, how we stay in business
Do you know what and how to collect data?

43. Sterile Processing
From Acquisition to Reuse

44. Sterilization of Equipment
Certified technicians
Cleaning …ultrasonic (5 to 10 min) open instruments …DRY/inspect
Wrapping … trays
test pack should be placed horizontally in the front, bottom section of the sterilizer rack, near the door and over the drain, in an otherwise empty chamber and run at 134oC for 3.5 minutes. Positive spore test results are a relatively rare event 838 and can be attributed to operator error, inadequate steam delivery 839, or equipment malfunction.

45. Sterilization
- Steam 121oC (250oF) and 132oC (270oF). Manufacturers recommendation.
Bowie-Dick test is used to detect air leaks and inadequate air removal
Biological monitor: Geobacillus stearothermophilus (formerly Bacillus stearothermophilus)
Monitored using a printout (or graphically) by measuring
temperature, the time at the temperature, and pressure
- Sterrad
-Portable (table-top) steam sterilizers
- Immediate use
quick chart

46. Correct loading /unloading
Sufficient space must occur around the packages
place items on edge and no chamber wall touching
do not stack packages or cassettes one upon the other
paper of one pouch next to the plastic of the adjacent pouch
Basins, bowls or other devices on their sides
running a load with both linens and medical instruments, place the linen packs on the top shelf
heavy medical items or large trays flat on the bottom shelves
Some steam sterilizers have an automatic dry cycle
opening the door about ½ inch after the pressure equalizes and let items sit inside the chamber for 30 to 60 minutes
Wet packages that exist at the end of steam-sterilization cycles should not be handled

47. Steam Sterilizer recall
Recalls due mechanical, chemical and biological
-Who you going to call?
Retrieval of processed items
Notify your sterilizer service representative
Re-validated with three consecutive negative biological monitors in three consecutive cycles
AAMI recommends that sterilizers be biologically monitored at least once a week, preferably daily, when normal cycles are used, in each flash sterilization load and in any load containing an implantable device.
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