Presentation on theme: "Prevention of Surgical Site Infections (SSI)"— Presentation transcript:
1 Prevention of Surgical Site Infections (SSI) MSIPC Fundamentals of Infection Prevention & ControlOctober 2014Karen Hoover, RNInfection Prevention CoordinatorSt. Mary’s of Michigan, Saginaw
2 SSI: A Complication of Surgical Care > 51.4 million surgical procedures/year in US31% of all HAI’s due to SSI, second only to UTI> 91,000 readmissions for SSI Rx1 million additional inpatient days1.6 billion excess costsAssociated mortality rate of 3%Cost… Pay for performance …patient safetyCDC’s Guideline for Prevention of Surgical Site Infection,Jan 2014 CDCCoding in past
3 Common surgical/Procedures 719,000/year Total knee498, hysters395, CABG332, Total HipAmbulatory1.3 million cataracts923,000 Lens implants779,000 Endoscopies735,000 Injections of spineApprox. 40% have more than 1 procedureCDC
4 Risk Factors for SSI: identification & opportunities for intervention Risk factor: variable with significant, independent association with development of SSIPatient: age, nutrition, diabetes, smoking, obesity, immunocompromised, pre-op LOS, micro-flora, other infectionSSI prevention measure: action(s) to reduce SSI risk, antibiotic prophylaxis, skin prep/antisepsisOperation: …patient & peri-op personnel, duration, antibiotic redosing,, surgical asepsis, traffic flow, surgical technique (robotic), hair removal, immediate use sterilizationEnvironmental: cleaning, disinfectant contact time, UV light, OR environment-HVACRisk 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 siteMeasures to neutralize that do gain access to siteReduce that which is conducive to infectionEnhance the host defenses - look at risk factorsFollow established guidelines
6 Pathogenesis of Surgical Site Infection (SSI) Dose x virulenceResistance of Host= risk of SSI> 105 / gm tissue risk; with foreign body only 100/gm is needed to cause SSIPathogens:Endogenous – flora normally containedExogenous – healthcare personnel, environment, devices/materials usedTwenty percent of bacterial skin flora resides in skin appendages, such as sebaceous glands, hair follicles, andsweat 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 bacteriaVirulence of bacteriaMicroenvironmentHost defensesEndogenous – 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 evaluatedSSI rate 12% S vs 2 % in NSSSI rate significantly less for S if abstain for 4wks (27% vs.1.1%)Wound rupture: 12% S vs. 0% NSWhen 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 - chlorhexidineCDC SSI Guidelines: Require patients to bathe with antiseptic on at least the night before their operationCHG cloth use night before & day of surgery
12 Intranasal Mupirocin & Prevention of SSI Orthopedic & cardiothoracic patients - significant reduction in SSI among treated1-3However these were retrospective & used historical controlsAnother randomized trial in ortho.surg found less S. aureus nasal carriage but no signif. Reduction in SSI rate41. Kluytmans JAJW. ICHE 1996;17:780-5.2. Cimochowski GE. Ann ThoracSurg 2001;71:3. Wilcox MH. J Hosp Infect 2003;54(3):4. Kalmeijer MD. Clin Infect Dis2002;35:353
13 Preventing Surgical Site Infection: System-level success [Usry GH, et al. AJIC 2002;30:434-6.]Intervention:Intranasal mupirocin48 hrs prior to through 5 days post opResults:94% of patients RxRate of SSI dropped by: 53% overall55% for deep sternalRatePer100CABGs
14 Surgical Care Improvement Project (SCIP) Antibiotic Timing - <60minAntibiotic Selection – type/body locationof procedure- dosing for body wt.- duration of procedure- PCN allergy?- cost of antibiotic2006AncefVancomycin or Clindamycin
15 Surgical Care Improvement Project (SCIP) within 24 hours surgery end time(SStop ATB 24 Hours end time 48 for Cardiac SurgeryBlood sugar <200 at 6 am POD 1 & 2S < 200 by 6STTTTTTGKLBLK a.m. POD 1 & 2 forAppropriate Hair removal …no razorsDVT ProphylaxisBeta-blocker given before OR and after unless contraindicatedDVTeICD (Int. Compression Device), TED’s, Heparin, WarfarinFoley cath …remove by POD 2 or physician note why notimplementing 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 products2) catheter-associated urinary tract infections3) pressure ulcers4) Vascular catheter associated infection5) Mediastinitis after CABG surgery6) Patient falls7) VAE8) Influenza vaccination rates9) Future: MRSA, S. aureus BSI, CDAD (C. diff)
17 Impact of SSI Occurring After Discharge * Many/Most SSI not identified until after dischargeCost for care with SSI were 2.9 times greater23% of readmits & 18% of ER visit …some at other facilitiesPost discharge SSIs can impair physical & mental healthSurveillance (PDS) is inconsistent …phone/paper …honestEducation - ? enough/consistent/updatedHost defense – acute and chronic medical conditionsEffective management to minimize consequencesExample of GG, G & Mom with hyster LOS
18 . ICD – 9 – CM codes Stitch/ Superficial Deep Pt. DOB Surg Class Room Procedure DescriptionStapleIncisionalJ5/22/633/71OR 12DECOMPRESSIVE LAMINECTOMY L4-5, L5-S1, NEURO FORAMOTOMY L4-5, L5-S14/8/54KNEE ARTHROSCOPY LEFT7/29/593/30KNEE ARTHROSCOPY RIGHT, PARTIAL MENISCECTOMY,6/20/623/14KNEE ARTHROSCOPY LEFT, PARTIAL MENISECTOMY, PARTIAL CHONDROPLASTY11/19/683/21KNEE ARTHROSCOPY RIGHT, PARTIAL CHONDROPLASTY, RELEASE PLICA1/28/323/28KNEE TOTAL ARTHROPLASTY LEFT8/31/91left KNEE ARTHROSCOPY with fixation of osteochondyle fx, debridement of8/18/40LEFT TOTAL HIP REPLACEMENT9/10/303/11OR 10OPEN REDUCTION, PINNING RIGHT FEMORAL NECK1/29/053/15OR 8REALINEMENT WITH PINNING AND CASTING LEFT ELBOW9/16/60RELEASE OF ACHILLES TENDON RIGHT2/24/32REMOVAL OF FOREIGN BODY RIGHT THIGH ANTIBIOTIC BEADS5/14/59REVISION LEFT TOTAL KNEE ARTHROPLASTY, EXTENSIVE SYNOVECTOMY11/1/44REVISION, POLY LEFT KNEE, DEBRIDMENT, LATERAL RELEASE1/13/25RIGHT KNEE ARTHROSCOPY, CHONDROPLASTY, PARTIAL MENISCECTOMY12/1/38RIGHT OPEN QUADRICEPS REPAIR WITH AFLEX GRAFTStitch/staple:minimal inflammation and discharge confined to the points of suture penetrationSuperficial Incisional:Purlent drainage from the superficial incision; or pain or tenderness, localized swelling, redness, orheat, and superficial incision is deliberately opened by surgeon, and is culture-positive or not culturedIf from secondary incison (e.g., donor site [leg] incision for CABG), please note: Y- SISDeep incisional :a. purulent drainage from the deep incision but not from the organ/spaceb. incision spontaneously dehisces or is deliberately opened by a surgeon and is culture-positive or not culturedduring 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 settingsShort lengths of stay + inter-facility transfer is commonNetworking!
20 Ambulatory Surgery: Risk Free? Cluster of Endoph-thalmitis after cataract surg.Acremonium kiliense4 patientsRisk Factor (RF): 1st case, MondaysHumidified air in ventilation likely sourceFridkin SK. Clin Infect Dis 1996;Steroid Injection OutbreakCluster of fungal contamination of saline breast implantSaline bottle stored under water-damaged ceiling &OR in negative pressureKainer 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 officerThe infection control condition places accountability on ASCs to prevent, control, andinvestigate 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 + waterSSI rate in hand rub (2.4%) vs scrub (2.5%) not signif.Better compliance, less skin irritation/dryness with hand rub in personnelCurrent 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;288:722-77WHO
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? …expensiveAnemia & 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 ORavoid hair removal but if needed use clippersAsepsis & technique:aseptic principles: IV, inserting catheters, administering medicationsAJIC 1999;27:97-132
27 Category IB SSI Prevention Recommendations Intraoperative:Positive pressure in ORMin. 15 air changes/hourFilter supply airKeep OR doors closed as much as possiblesterilize surgical instruments; limit flash sterilizationSurgical Team:surgical mask, hair covergown & sterile glovesGentle handling of tissueAJIC 1999;27:97-132
28 Category IB SSI Prevention Recommendations Surveillance:Use CDC definitionsApply risk indexPeriodically calculate risk stratified SSI ratesReport SSI rates to surgical personnelUse standard case finding methodsAJIC 1999;27:97-132
29 Surgical Site Infection Criteria Superficial incisional SSIInfection occurs within 30 days after any NHSN operative procedure andinvolves only skin and subcutaneous tissue of the incision andpatient 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 culturedand 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 attendingphysician 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 thathas 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 apatient 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 SSIDiagnosis of “cellulitis”, by itself, does not meet criterion d for superficial incisional SSI.
31 Deep incisional SSIInfection occurs within 30 or 90 days after the NHSN operative procedure andinvolves deep soft tissues of the incision (e.g., fascial and muscle layers) andpatient has at least one of the following:a. purulent drainage from the deep incision.b. a deep incision that spontaneously dehisces or is deliberatelyopened by a surgeon and is culture-positive or not culturedand 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 deepincisiond. diagnosis of a deep incisional SSI by a surgeonor attending physician or other designee
32 Organ/Space SSIInfection occurs within 30 or 90 days after the NHSN operative procedure andinfection involves any part of the body, excluding the skin incision, fascia, or muscle layers, that is opened or manipulated during the operative procedure andpatient has at least one of the following:a. purulent drainage from a drain that is placed into the organ/spaceb. organisms isolated from an aseptically-obtained culture offluid or tissue in the organ/spacec. an abscess or other evidence of infection involving theorgan/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 accompaniedbyosteomyelitis as SSI-MED rather than SSI-BONE.• If meningitis (MEN) and a brain abscess (IC) are present togetherafter operation, report as SSI-IC.• Report CSF shunt infection as SSI-MEN if it occurs within 90 daysof placement; if later or after manipulation/access, it isconsidered CNS-MENReport spinal abscess with meningitis as SSI-MEN following spinalsurgery.
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 PlanJust %? …what if 1 of 2 procedures develop SSI?Denominator & numerator?GraphsPrevious year …2 years?ScorecardsCompare with NNIS vs Standard Infection Ratio (SIR)Special InvestigationsHigh volume surgerySurgeon specific?“Tell them/show them what they need to see”
38 Post discharge Data Surveillance: Patient NameDOBSurgeryClassRoomProcedure DescriptionName of hospital_________________Education: New surgeons/Annually (definitions)Skin/staple related? …don’t countIncisional … skin or sub-Q , drainage, dehisence, I&DAny 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) surgeriesAction 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 effectiveSurveillance & Interventional Epidemiology is an effective component of a facility’s patient safety/performance improvement programFeedback 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 evolveGovernment agencies will change how we measure quality performanceReimbursement can effect our process, advancing to new equipment or products, how we stay in businessDo you know what and how to collect data?
44 Sterilization of Equipment Certified techniciansCleaning …ultrasonic (5 to 10 min) open instruments …DRY/inspectWrapping … traystest 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 removalBiological monitor: Geobacillus stearothermophilus (formerly Bacillus stearothermophilus)Monitored using a printout (or graphically) by measuringtemperature, the time at the temperature, and pressure- Sterrad-Portable (table-top) steam sterilizers- Immediate usequick chart
46 Correct loading /unloading Sufficient space must occur around the packagesplace items on edge and no chamber wall touchingdo not stack packages or cassettes one upon the otherpaper of one pouch next to the plastic of the adjacent pouchBasins, bowls or other devices on their sidesrunning a load with both linens and medical instruments, place the linen packs on the top shelfheavy medical items or large trays flat on the bottom shelvesSome steam sterilizers have an automatic dry cycleopening the door about ½ inch after the pressure equalizes and let items sit inside the chamber for 30 to 60 minutesWet 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 itemsNotify your sterilizer service representativeRe-validated with three consecutive negative biological monitors in three consecutive cyclesAAMI 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.for online info & quiz