Presentation is loading. Please wait.

Presentation is loading. Please wait.

Prevention of Surgical Site Infections William A. Rutala, Ph.D., M.P.H. UNC Health Care System and UNC School of Medicine, Chapel Hill, NC.

Similar presentations


Presentation on theme: "Prevention of Surgical Site Infections William A. Rutala, Ph.D., M.P.H. UNC Health Care System and UNC School of Medicine, Chapel Hill, NC."— Presentation transcript:

1 Prevention of Surgical Site Infections William A. Rutala, Ph.D., M.P.H. UNC Health Care System and UNC School of Medicine, Chapel Hill, NC

2 Disclosure This educational activity is brought to you, in part, by Advanced Sterilization Products (ASP) and Ethicon. The speaker receives an honorarium from ASP and Ethicon and must present information in compliance with FDA requirements applicable to ASP.

3 TOPICS l Epidemiology of healthcare associated infections (HAI) l Review the morbidity, mortality, and economic consequences of HAIs l Discuss the risk factors and etiology of SSIs l Provide strategies to prevent SSIs l National initiatives to prevent SSIs

4 Healthcare-Associated Infections (HAIs) l HAIs are those that develop in the hospital that were neither incubating nor present at the time of admission l 40 million persons hospitalized annually in US; 5% or 2M will develop a HAI Morbidity and mortality (90,000 deaths); 6 th leading cause of death in the US Variable prolongation of hospital stay $5-10 billion/year

5 Impact of Healthcare-Associated Infections

6 Cost Estimates for Specific Healthcare-Associated Infections HAI typeWeight-Adjusted Cost per HAI Mean + SE Range of Published Estimates of Cost per HAI VAP25, ,1328,682-31,316 BSI23, ,1846,908-37,260 SSI10, ,2492,527-29,367 CA-UTI US dollars Anderson DJ, et al. ICHE 2007;28:

7 UNC Hospitals Selected HAIs and Estimated Cost HAI typeUNC Cases, 2006Estimated Cost, $ VAP85 2,131,120 BSI297 6,902,874 SSI266 2,777,838 CA-UTI ,738 Total95912,047,570 Total cost estimated by multiplying number of cases at UNC Hospitals by mean cost derived from Duke meta-analysis

8 Most Prevalent Weinstein RA. Emerg Infect Dis. 1998;4(3): CDC, NNIS Semiannual Report, Dec 2000.

9 Surgical Site Infection

10 l SSIs third most common HAI, accounting for 14-16% of HAIs l Among surgical patients, SSIs were most common accounting for ~40% of healthcare-associated infections 67% incisional infections (confined to incision) 33% organ/space infections l Increase an average of 7 days to each hospitalization l Increase >$10,000 (2005 $) to each hospitalization l Appropriate preoperative administration of antibiotics and other prevention measures are effective in preventing infection Surgical Site Infections. Available at: Odom-Forren J. Nursing ;36(6):58-63.

11 Surgical Site Infection l Advances in infection control practices Improved operating room ventilation Sterilization methods Barriers Surgical technique Antimicrobial prophylaxis

12

13 Challenges in the Prevention and Management of Surgical Site Infections l Changing population of hospital patients Increased severity of illness Increased numbers of surgical patients who are elderly Increased numbers of chronic, debilitating or immunocompromising underlying diseases Shorter duration of hospitalization Increased numbers of prosthetic implant and organ transplant operations performed l Public reporting of infection rates/proportions l Growing frequency of antimicrobial-resistant pathogens l Non-reimbursement for “medical errors”-CMS l Lack of compliance with hand hygiene

14 Clinical and Economic Impact Procedure/DeviceDevices/yr*Infections/yrAvg. costMortality* CARDIO Heart valves85,0003,400$50,000High Vascular grafts450,00016,000$40,000Moderate Pacemaker/ICD300,00012,000$35,000Moderate LV assist dev $50,000High NEURO CNS shunt40, $50,000Moderate Adapted from: Darouiche RO. N Engl J Med. 2004;350: *Darouiche RO. Clin Infec Dis. 2001;38:

15 Clinical and Economic Impact Procedure/DeviceDevices/yr*Infections/yrAvg. costMortality* ORTHOPEDIC Joint prosthesis600,00012,000$30,000Low Fracture fixator2,000,000100,000$15,000Low PLASTIC Breast implant130, $20,000Low UROLOGICAL Penile implant15,000450$35,000Low Adapted from: Darouiche RO. N Engl J Med. 2004;350: *Darouiche RO. Clin Infec Dis. 2001;38:

16 SSI: Pathogenesis Risk of surgical site infections = Dose of bacterial contamination x virulence (toxins) Resistance of the host

17 SSI: Primary Risk Factors l Endogenous microorganisms Skin-dwelling microorganisms  Most common source  S aureus most common isolate  Fecal flora (gnr) when incisions are near the perineum or groin l Exogenous microorganisms Surgical personnel (members of surgical team) OR environment (including air) All tools, instruments, and materials Mangram AJ, et al. Infect Control Hosp Epidemiol. 1999;20(4):

18 SSI: Microbiology (NNIS, 1996)

19 PATHOGENS ASSOCIATED WITH SSIs: NHSN, Hidron AI, et al. ICHE 2008;29:

20

21 To Reduce the Risk of Surgical Site Infection A simple but realistic approach must be applied with the awareness that the risk of SSIs is influenced by characteristics of the patient, operation, personnel and hospital Mangram AJ, et al. Infect Control Hosp Epidemiol. 1999;20(4):

22 CDC: SSI Recommendations, 1999 l Definitions IA: Strongly recommended for all hospitals and strongly supported by experimental or epidemiologic studies IB: Strongly recommended for all hospitals and viewed as effective by experts II: Suggested for implementation in many hospitals; suggestive clinical or epidemiologic studies, strong theoretical rationale

23 SSI: CDC Guidelines Patient characteristics Preoperative issues Intra-operative issues Postoperative issues Mangram AJ, et al. Infect Control Hosp Epidemiol. 1999;20(4):

24 SSI: CDC Guidelines Patient characteristics/risk factor Preoperative issues Intra-operative issues Postoperative issues Mangram AJ, et al. Infect Control Hosp Epidemiol. 1999;20(4):

25 Risk and Prevention in SSIs Risk Factor-a variable that has a significant independent association with the development of SSI after a specific operation

26 SSI: Intrinsic/Patient Risk Factors l Age-extremes l Nutritional status-poor l Diabetes-controversial; increased glucose levels in post-op period ↑ risk l Smoking-nicotine delays wound healing ↑ risk l Obesity>20% ideal body weight l Remote infections ↑ risk l Endogenous mucosal microorganisms l Preoperative nares S. aureus- CT patients l Immunosuppressive drugs may ↑ risk l Preoperative stay-surrogate for severity of illness

27 Prevention of SSIs l Preoperative preparation of the patient Minimize preoperative stay (II) Identify and treat remote site infections (IA) Adequately control glucose in diabetics (IB) Encourage discontinuation of tobacco for 30d (IB). Consider delaying elective procedures in severely malnourished patients (II) No recommendations to taper or discontinue steroids (Unresolved issue)

28

29 SSI: CDC Guidelines Patient characteristics Preoperative issues Intra-operative issues Postoperative issues Mangram AJ, et al. Infect Control Hosp Epidemiol. 1999;20(4):

30 SSI: Preoperative Issues Modifiable Risks Glucose control-in diabetic patients Preoperative CHG shower Appropriate hair removal Hand hygiene Skin antisepsis Antimicrobial prophylaxis Normothermia-hypo higher risks Mangram AJ, et al. Infect Control Hosp Epidemiol. 1999;20(4): Million lives. Institute for Healthcare Improvement. Available at: Accessed on February 8, 2007.

31 Prevention of SSIs l Preoperative preparation of the patient Preoperative showers with antiseptic agent at least the night before (IB) Do not remove hair preoperatively unless it will interfere with the operation (IA) If hair removed, remove just prior to surgery with electric clippers (IA) Wash and clean at and around incision site prior to performing antiseptic skin preparation (IB)

32 Preoperative Showers l Garibaldi R (J Hosp Infect 1988;11(suppl B):5 Reduction in bacterial counts: Chlorhexidine 9-fold, povidone-iodine 1.3-fold l Cruse and Foord ( Arch Surg 1973;107:206 ) Clean surgery  SSI rate, no shower = 2.3%  SSI rate, shower with soap = 2.1%  SSI rate, shower with hexachlorophene = 1.3%

33 Chlorhexidine: Preoperative Showers l CDC recommends preoperative showering with antiseptic 1 l CHG more effective than PI and triclocarban l Lower rates of intraoperative wound contamination 1. Mangram AJ et al. Infect Control Hosp Epidemiol. 1999;20(4): Garibaldi RA. J Hosp Infect. 1988;11(suppl B):5-9.

34 Chlorhexidine: Preoperative Showers Patients who had 2 preoperative showers with CHG 24 hours before surgery had reduced rates of wound infection compared to patients who showered with soap. Hayek LJ, et al. J Hosp Infect. 1987;10(2):

35 CHG Concentration (PPM) Skin Sites Left Elbow Right Elbow Abdominal Left Knee Right Knee 4% Chlorhexidine Gluconate (CHG) Shower - Mean Skin Surface Concentration (N=60) MIC 90 = 4.8 ppm Group 2A “Morning (AM)” Group 3A “Both (AM and PM)” CHG Shower CHG Shower Group 1A “Evening (PM)” p <0.05 NSP<0.001 Edmiston et al, J Am Coll Surg 2008;207:

36 Preoperative Hair Removal l Seropian and Reynolds (Am J Surg 1971;121:251) SSI rate, razor-shave (microabrasions) = 5.6%  SSI rate, razor-shave >24 hours = 20%  SSI rate, razor-shave within 24 hours = 7.1%  SSI, razor-shave immediately preop = 3.1% SSI rate, no removal or depilatory = 0.6%

37 Preoperative Hair Removal l Cruse and Foord (Arch Surg 1973;107:206) SSI rate, razor-shave = 2.5% Manual hair clipped = 1.7% Electric hair clipper = 1.4% No shave or clip = 0.9%

38 SSI: Preoperative Issues Modifiable Risks Glucose control-in diabetic patients Preoperative CHG shower Appropriate hair removal Hand hygiene Skin antisepsis Antimicrobial prophylaxis Normothermia-hypo higher risks Mangram AJ, et al. Infect Control Hosp Epidemiol. 1999;20(4): Million lives. Institute for Healthcare Improvement. Available at: Accessed on February 8, 2007.

39 Prevention of SSIs l Preoperative preparation of the surgical team Keep nails short and no artificial nails (IB) Perform preoperative surgical scrub for 2-5 minutes with antiseptic-alcohol, chlorhexidine, iodophors (IB); new waterless, surgical hand antisepsis with alcohol Perform preoperative scrub including forearms (IB) Do not wear hand/arm jewelry (II) Prohibiting nail polish (No recommendation)

40 Importance of Our Skin Largest organ of the body  Epidermis  Dermis  Subcutaneous tissue (hypodermis)

41 Importance of Our Skin Microorganisms 80% in first 5 cell layers of epidermis l When skin is perforated Integrity is compromised  infection risk #1 Function: Protective Barrier

42 Normal Skin Micro-Flora Numbers per square centimeter of skin surface (cfu/cm 2 ). Counts on hands range from 3.9x10 4 to 4.6x10 6. Numbers of bacteria that colonize different parts of the body

43 Surgical Hand Antisepsis

44 Alcohols AdvantagesDisadvantages Broad spectrum Effective against:  Most gram-positive  Most gram-negative  Fungi  Viruses Rapid acting Short persistence Potentially drying to skin Potentially flammable Spores may be resistant Not applicable for mucosal membranes Larson EL.. Am J Infect Control. 1995;23(4): Boyce JM, et al. MMWR Recomm Rep Oct 25;51(RR-16):1-45. Crosby CT, Mares AK. JVAD. 2001:1-6.

45 Iodine/Iodophors AdvantagesDisadvantages Broad spectrum Effective against  Most gram-positive  Most gram-negative  Fungi  Viruses Some activity against spores Diminished efficacy by organic material (e.g., blood) Variable persistence Irritates skin Larson EL.. Am J Infect Control. 1995;23(4): Boyce JM, et al. MMWR Recomm Rep Oct 25;51(RR-16):1-45. Crosby CT, Mares AK.. JVAD. 2001:1-6.

46 Chlorhexidine AdvantagesDisadvantages Broad spectrum Effective against  Most gram-positive  Most gram-negative  Fungi  Viruses  Yeast Highly persistent Effective in the presence of organic material (e.g., blood) Minimally absorbed Direct instillation can damage ears or eyes Direct contact with nerve tissue can be damaging Minimal activity against spores Larson EL. Am J Infect Control. 1995;23(4): Hidalgo E, Dominguez C. Toxicol In Vitro. 2001;15(4-5): Maki DG, et al. Lancet. 1991;338: Larson E, Bobo L.. J Emerg Med. 1992;10(1):7-11. Boyce JM, et al. MMWR Recomm Rep Oct 25;51(RR-16):1-45. Anders N, Wollensak J. J Cataract Refract Surg. 1997;23(6): Perez R, et al. Laryngoscope. 2000;110(9):

47 Surgical Hand Antisepsis l Surgical hand scrubs should: Significantly reduce microorganisms on intact skin Contain a non-irritating antimicrobial preparation Have broad-spectrum activity Be fast-acting and persistent

48 Active Agents Tincture of Iodine Traditional IodophorsCHG/ Alcohol Broad SpectrumXXX Rapid ActivityXXX Residual ActivityX Activity in Blood/OrganicX Non-IrritatingX Minimal AbsorptionX Combined Agents

49 Surgical Hand Antisepsis l Formulations containing 60-90% alcohol alone, or % when combined with small amounts of a QUAT, or CHG lower bacterial counts on skin post-scrub more effectively than other agents l Next most active agents (in order of decreasing activity) are CHG, iodophors, triclosan, and plain soap l Alcohol-based preparations containing 0.5-1% CHG have persistent activity but alcohol alone may not

50

51 Surgical Hand Antisepsis l Studies suggest that neither a brush nor a sponge is necessary to reduce bacterial counts on the hands of surgical personnel to acceptable levels, especially when alcohol-based products are used l One study (AORN J 2001;73:412) found a brushless application of a preparation of 1% CHG plus 61% ethanol yielded lower bacterial counts on the hands of participants than using a sponge/brush to apply 4% CHG

52

53

54

55

56 Prevention of SSI l Preoperative preparation of the patient Use appropriate antiseptic for skin preparation (IB)  Alcohol (70-92%)  Chlorhexidine 4%, 2% or 0.5% in alcohol base  Iodine/iodophors  Apply in concentric circles moving to periphery  Prep area to include incision and any drain sites

57 Chlorhexidine l Highly effective in studies of hand washing preoperative showering IV catheter care l CHG has a broad spectrum of activity Rapid Persistent Active w/ organic material Non-irritating Recommended in 15 evidence-based guidelines (hand hygiene, catheter-related bloodstream infection) Larson E.. Am J Infect Control. 1995;23(4): Maki DG, et al. Lancet. 1991;338:

58 2% CHG/70% IPA vs. 10% PVP-I l Randomized, parallel group, open label, healthy human volunteers l 55 subjects l Microbial samples: right and left abdominal and inguinal sites l Efficacy defined as ≥2.0 log 10 reduction from baseline CFUs/cm 2 on abdominal sites ≥3.0 log 10 mean reduction from baseline CFUs/cm 2 on inguinal sites Hibbard JS. J Infus Nursing. 2005;28(3):

59 2% CHG/70% IPA vs. 10% PVP-I 2% CHG/70% IPA vs. 10% PVP-I AbdominalInguinal P= compared to baseline for all results Hibbard JS. J Infus Nursing. 2005;28(3):

60 2% CHG/70% IPA for Foot and Ankle Surgery l Prospective, randomized trial l 125 evaluable patients 40 subjects/group 5 pre-prep baseline l Products ChloraPrep® (2% CHG/70% IPA) DuraPrep® (0.7% Iodine/74% IPA) Techni-Care® (3% Chloroxylenol-PCMX) l Cultures: hallux, web spaces between toes, and control site Ostrander RV, et al. Bone Joint Surg Am. 2005;87(5):

61 2% CHG/70% IPA for Foot and Ankle Surgery Ostrander RV, et al. J Bone Joint Surg Am. 2005;87-A: Control = anterior tibia, 12 cm proximal to the ankle joint.

62 2% CHG/70% IPA for Foot and Ankle Surgery Ostrander RV, et al. J Bone Joint Surg Am. 2005;87-A:

63 Prevention of SSIs l Preoperative preparation of the surgical team Clean underneath each fingernail prior to first surgical scrub (IB) After performing surgical scrub keep hands up and away from body; allow water to run from hands to elbows; dry with sterile towel (1B)

64

65 Prevention of SSIs l Management of infected or colonized surgical personnel Exclude from duty, surgical personnel who have draining skin lesions until infection eliminated or personnel have received adequate therapy (IB) Do not routinely exclude personnel colonized with S. aureus or group A strep unless personnel linked epidemiologically to outbreak (IB) Educate personnel regarding symptoms and signs of infection-have them report to OHS (IB)

66 Prophylactic Antibiotics Antibiotics given for the purpose of preventing infection when infection is not present but the risk of postoperative infection is present. Cefazolin is widely used for clean operations.

67 Surgical Infection Prevention Arch Surg 2005;140:174 l 40.7 l 92.9 l 47.6 l All Surgeries (34,133) l 79.1 l 90.8 l 52.4 l Hysterectomy (2,756) l 41.0 l 75.9 l 40.6 l Colon (5,279) l 36.3 l 97.4 l 52.0 l Hip/knee (15,030) l 44.8 l 91.9 l 40.0 l Vascular (3,207) l 34.3 l 95.8 l 45.3 l Cardiac (7,861) l Antibiotic stopped within 24 hours l % l Correct Antibiotic l % l Antibiotic within 1 hour l % l Surgery (N)

68 Prevent Surgical Site Infections: Institute for Healthcare Improvement l Components if implemented reliably can eliminate SSIs Appropriate use of antibiotics: one hour before incision; appropriate antibiotics; discontinue with 24 h after surgery (Surgical Care Improvement Project-CMS Quality Indicator) Appropriate hair removal Maintenance of postoperative glucose control (<200mg/dl) for major cardiac surgery patients Establishment of postoperative normothermia for colorectal surgery patients

69

70 SSI: CDC Guidelines Patient characteristics Preoperative issues Intra-operative issues Postoperative issues Mangram AJ, et al. Infect Control Hosp Epidemiol. 1999;20(4):

71 SSI: Primary Risk Factors l Endogenous microorganisms Skin-dwelling microorganisms  Most common source  S aureus most common isolate  Fecal flora (gnr) when incisions are near the perineum or groin l Exogenous microorganisms Surgical personnel (members of surgical team) OR environment (including air) All tools, instruments, and materials Mangram AJ, et al. Infect Control Hosp Epidemiol. 1999;20(4):

72 OR Environment l Air Largest source of airborne microbial contamination is the OR staff Organisms become airborne as a result of conversation or shedding from the hair or exposed skin Microbial level directly proportional to the number of people moving about in the room Improved ventilation associated with decreased SSI

73 Prevention of SSIs l Intraoperative (Ventilation) Maintain 15 AC/hr (>3 fresh), positive pressure (IB) Filter all air through appropriate filters (IB) Introduce air at ceiling and exhaust near floor (IB) Keep OR doors closed as needed for passage of equipment, personnel, and patients (IB) Limit the number of OR personnel (IB) Consider ultraclean air for orthopedic implants (II)

74 OR Environment l Ventilation Three primary design components act to purify the OR air  High-flow ventilation - 15 air changes per hour (3 outside air)  High-efficiency filtration %  Positive pressure relative to adjacent areas (prevents contamination from less clean areas) Maintain the temperature ( F [ C]) and relative humidity (30-60%)

75 OR Environment l Environment as an Exogenous Source of Pathogens Clean environment minimizes the risk of OR environmental surfaces and floors as a source of infection Microorganisms isolated from the OR are usually non- pathogens rarely associated with infection When inanimate sources implicated, the sources have been contaminated solutions, antiseptics, or dressings (not floors, walls or environmental surfaces)

76 Prevention of SSIs l Intraoperative (Cleaning/disinfection environmental surfaces) Clean when visibly soiled/contaminated with EPA approved disinfectant before the next operation (IB) Do not perform special cleaning after contaminated or dirty surgery (IB) Do not use tacky mats (IB) Cleaning between surgery if no visible contamination (No recommendation)

77 OR Environment l Disinfection OR environment (furniture, lights, equipment) should be damp-dusted with a germicide on a scheduled basis Exogenous microorganisms can contaminate surgical practice setting Disinfection is essential to reduce the risk of cross-infection Disinfection of these surfaces will control airborne microorganisms that might travel on dust and lint

78 OR Environment l Disinfection Floors should be cleaned with a low-level disinfectant For end-of-use cleaning, necessary to clean a 3-to-4 ft perimeter around the operative site (extended as necessary by contamination) Important to reestablish a clean environment after each operation For terminal daily cleaning, entire floor is cleaned Same cleaning procedures performed whether clean or contaminated case

79 OR Environment l Disinfectants Low-level disinfectants are used for non-critical (skin contact) surfaces/furniture/lights  Phenolics  Quaternary ammonia compounds  Chlorine (1:10 dilution of 5.25% sodium hypochlorite- blood spills)

80 OR Environment l Reusable Items Clean (in accordance to manufacturer’s recommendation)  Lower the microbial load (mechanical or manual)  Reduces organic and inorganic residual Disinfect or sterilize based on the risk of infection associated with the use of the item  Critical items (sterile tissue, vascular system) must be sterile  Semicritical (endoscopes) must be high-level disinfected

81 OR Environment l Sterilization Inadequate sterilization of surgical instruments has resulted in SSI Surgical instruments can be sterilized by steam, ethylene oxide, hydrogen peroxide plasma, dry heat or other approved methods Microbial monitoring of sterilization performance is necessary and can be accomplished by biological indicators

82 Prevention of SSIs l Intraoperative (Sterilization of surgical instruments) Perform flash sterilization only for patient care items that will be used immediately. Do not use for reasons of convenience, as an alternative to purchasing additional instrument sets, or to save time (IB) Sterilize all surgical instruments according to published guidelines (IB)

83 OR Environment l Microbiologic Sampling No standardized parameters by which to compare microbial levels obtained from cultures of ambient air or environmental surface Routine microbiologic sampling cannot be justified Environmental sampling should only be performed as part of an epidemiologic investigation

84 Prevention of SSIs l Intraoperative (Surgical attire and drapes-minimize patient’s exposure to skin, mm, or hair of surgical team and protect team from exposure to blood and OPIM) Wear a mask to fully cover the mouth and nose, and a cap or hood to fully cover hair on head and face (IB) Wear sterile gloves (IB) Do not wear shoe covers to prevent SSIs (IB)

85 Prevention of SSIs l Intraoperative Use materials for surgical gowns and drapes that are effective barriers when wet (IB) Change surgical scrubs when visibly soiled, contaminated and/or penetrated by blood (IB)

86 Prevention of SSIs l Asepsis and surgical technique Adhere to the principles of asepsis when placing intravascular devices, spinal or epidural anesthesia catheters, or when dispensing and administering IV drugs (IB) Handle tissue gently, maintain effective hemostasis, minimize devitalized tissue and foreign bodies, and eradicate dead space at the surgical site (IB)

87 Prevention of SSIs l Asepsis and surgical technique Use delayed primary skin closure or leave an incision open to heal by second intention if the surgeon considers the surgical site to be heavily contaminated (IB) If drainage is necessary, use a closed suction drain. Place a drain through a separate incision distant from the operative incision. Remove the drain as soon as possible. (IB)

88

89 SSI: CDC Guidelines Patient characteristics Preoperative issues Intra-operative issues Postoperative issues Mangram AJ, et al. Infect Control Hosp Epidemiol. 1999;20(4):

90 Prevention of SSIs l Postoperative Incision Care Protect with a sterile dressing for hours postoperatively an incision that has been closed primarily (IB) Wash hands before and after dressing changes and any contact with the surgical site (IB)

91 Prevention of SSIs l Surveillance Use CDC definitions of SSI (IB) When postdischarge surveillance is performed, use a method that accommodates available resources and data needs (II) Assign surgical wound classification upon completion of an operation (II) Record key variables shown to be associated with SSI (wound classification, ASA class, duration of operation)(IB)

92 Surveillance at UNC Hospitals l Follow certain operations for SSIs and benchmark Vaginal hysterectomy CABG Cholecystectomy Knee replacement Mastectomy Ventricular shunt Laminectomy

93 Prevention of SSIs l Surveillance Periodically calculate operation-specific SSI rates (IB) Report stratified, operation-specific SSI rates to surgical team members (IB) Provide infection control committee with coded surgeon specific data (No recommendation)

94 CDC Surgical Site Infection Prevention Guidelines Category IA and IB No prior infections15 air changes/hr in OR Do not shave in advanceKeep OR doors closed Control glucose in D.M. ptsUse sterile instruments Stop tobacco useWear a mask Shower with antiseptic soapCover hair Prep skin with approp. agentWear sterile gloves Surgical team nails shortGentle tissue handling Surgical team scrub handsDPC for heavily contaminated Exclude I/C surgical team wounds Give prophylactic antibioticsClosed suction drains (when used) Pos pressure ventilation in ORSterile dressing x hr SSI surveillance with feedback to surgeons

95 PLUS Antibacterial Sutures l Antibacterial agent (triclosan) kills bacteria and inhibits colonization of the suture l Proven in vitro to create a zone of inhibition around the suture against common SS pathogens: S. aureus, MRSA, CONS l Triclosan-coated sutures may be valuable in reducing SSIs. Ann Thorac Surg 2007:87:232 l Hospitals challenged with the question whether to invest in this technology for routine surgical wound closure-must review data on SSI reduction, cost of surgical wounds, wound care, prolonged hospitalization, suture cost, etc

96 National Organizations Targeting Infection Prevention as a Measure of Quality l Centers for Medicare and Medicaid Services (CMS) l Institute for Healthcare Improvement (IHI) l National Quality Forum l The Joint Commission l Consumers Union-report HAIs

97 Center for Medicare and Medicaid Services FY2008 l Rule adopts eight conditions for which CMS will not provide higher payments if the event occurs while a patient is under the care of the hospital, effective FY09 Object left in surgery Air embolism Blood incompatibility

98 Center for Medicare and Medicaid Services FY2008 l CMS will not provide higher payments Catheter-associated urinary tract infections Pressure ulcers Vascular catheter associated infections Mediastinitis after coronary artery bypass graft Falls l Agency intends to consider other HAIs and medical errors for non-payment in future years l Hospitals cannot bill patients for the amount CMS refuses to pay

99 Center for Medicare and Medicaid Services FY2008 l Intent Mobilize hospitals to improve care and keep patients safe Consensus among public health experts that HAI/errors are preventable Encourage stricter adherence to proven infection prevention practices l Unintended Consequences Avoidance of patients perceived to be at risk for infections Hospitals may game the system by falsifying codes to avoid non-payment

100 Public Reporting of HAIs l Advisory Commission on Hospital Infection Control Purpose: prepare hospitals for the public disclosure of HAIs as may be required by law for specific clinical procedures  Class I surgical site infections  Ventilator-associated pneumonia  Central-line related bloodstream infections Must ensure quality and accuracy of information Commission will submit an interim report May 2008 and final report 2009 General Assembly

101 Prevent Surgical Site Infections: Institute for Healthcare Improvement l Components if implemented reliably can eliminate SSIs Appropriate use of antibiotics Appropriate hair removal Maintenance of postoperative glucose control for major cardiac surgery patients Establishment of postoperative normothermia for colorectal surgery patients

102 Conclusions l Surgical site infections result in significant patient morbidity and mortality, and increased hospital cost l Reduction in surgical site infections can be achieved by strict adherence to standard surgical guidelines l Observations have revealed failure to follow standard guidelines l Strict adherence to standard guidelines crucial to reduce SSIs

103 TOPICS l Epidemiology of healthcare associated infections (HAI) l Review the morbidity, mortality, and economic consequences of HAIs l Discuss the risk factors and etiology of SSIs l Provide strategies to prevent SSIs l National initiatives to prevent SSIs

104 Thank you

105


Download ppt "Prevention of Surgical Site Infections William A. Rutala, Ph.D., M.P.H. UNC Health Care System and UNC School of Medicine, Chapel Hill, NC."

Similar presentations


Ads by Google