1 Working Toward Zero Infection Rate Maureen Spencer, RN, MEd, CIC Infection Control Manager New England Baptist Hospital, Boston, Mass

2 Topics to be covered… New England Baptist Hospital and Orthopedics New England Baptist Hospital and Orthopedics What’s up in the Healthcare Community What’s up in the Healthcare Community Identifying Problems and Action Plans Identifying Problems and Action Plans Action Plans for Patients Action Plans for Patients The Evidence: What Were The Outcomes – rates and potential cost savings The Evidence: What Were The Outcomes – rates and potential cost savings

3 New England Baptist Hospital Boston, Massachusetts Orthopedic Center of Excellence New England Baptist Hospital Boston, Massachusetts Orthopedic Center of Excellence Acute inpatient discharges Acute inpatient discharges divided among 3 service lines: Orthopedic 75% General Surgery 8% Medical 17% Orthopedic Surgery ~ 10,000/cases a year Orthopedic Surgery ~ 10,000/cases a year 6000 inpatient, 4000 outpatient) 6000 inpatient, 4000 outpatient) 4000 total joints and 2000 spine/sports 4000 total joints and 2000 spine/sports

4 Total Inpatient Volume Massachusetts Market Orthopedic Surgery

5 New England Baptist Hospital Market Growth ~ 11%

6 The inpatient orthopedic surgical market is growing…… Demographics – older population and more active lifestyles Demographics – older population and more active lifestyles The emergence of new procedures (including minimally invasive surgery and artificial discs) The emergence of new procedures (including minimally invasive surgery and artificial discs) Greater penetration of existing technologies and biologics Greater penetration of existing technologies and biologics Increase in the most complex DRGs Increase in the most complex DRGs 1.Herndon JH. The future of orthopaedics. AAOS Bulletin (online). June 2004; 52:3. Available at Accessed May 16, 2006.

7 Orthopedic Surgical Site Infection Orthopedic Total Joint Infections: Orthopedic Total Joint Infections: Hip or Knee aspiration Hip or Knee aspiration If positive – irrigation and debridement If positive – irrigation and debridement Removal of hardware may be necessary Removal of hardware may be necessary Re-implantation at future date Re-implantation at future date Patient lives with no joint for period of time Patient lives with no joint for period of time Long-term IV antibiotics in community or rehab Long-term IV antibiotics in community or rehab Future worry about the joint Future worry about the joint In other words – DEVASTATING FOR THE PATIENT In other words – DEVASTATING FOR THE PATIENT

Established a Multidisciplinary Team The team included representatives from OR nursing, CSS OR nursing, CSS Orthopedic surgeons (Joint, Spine) & Anesthesia Orthopedic surgeons (Joint, Spine) & Anesthesia Managers from infection control, healthcare quality, facilities and environmental services Managers from infection control, healthcare quality, facilities and environmental services The team evaluated procedures, practices and facility design and prioritized action plans to institute changes and infection control measures. The team evaluated procedures, practices and facility design and prioritized action plans to institute changes and infection control measures.

9 Issues Identified Per Fiscal Year Traffic control Traffic control Surgical attire Surgical attire Operating room cleaning Operating room cleaning Processing of instruments Processing of instruments Air handling system and laminar flow Air handling system and laminar flow Surgical hand scrub Surgical hand scrub Surgical infection prevention (SIP) core measures Surgical infection prevention (SIP) core measures Silver postoperative dressings Silver postoperative dressings Antibacterial sutures Antibacterial sutures MRSA and MSSA Eradication Program - 2 ½ year process MRSA and MSSA Eradication Program - 2 ½ year process Chlorhexidine preop, intraop, post-op Chlorhexidine preop, intraop, post-op Post-op dressing procedures Post-op dressing procedures FY2003 FY2004 FY2005 FY2006 FY2008 FY2009

10 Communication Consistent and Timely Collaborative communication: Collaborative communication: consistent and timely manner consistent and timely manner infection rates and control measures infection rates and control measures ICP attends ICP attends Patient Care Assessment Committee Patient Care Assessment Committee Orthopedic Staff meeting Orthopedic Staff meeting Patient Care Operations and Hospital Operations Committees Patient Care Operations and Hospital Operations Committees Surgical and Orthopedic Grand Rounds on SSI Surgical and Orthopedic Grand Rounds on SSI Infection Control Liaison program Infection Control Liaison program

11 Action Plans and Implemented Control Measures

12 Operating Room Operating Room Re-train on the use of CHG/alcohol surgical scrub solution (6 hr residual activity) Re-train on the use of CHG/alcohol surgical scrub solution (6 hr residual activity) “Back to basics” training class for OR orderlies for room turnovers “Back to basics” training class for OR orderlies for room turnovers Improved traffic control: new signage and monitoring system Improved traffic control: new signage and monitoring system Cloth cap use – must be covered when in surgery and total hair coverage monitored Cloth cap use – must be covered when in surgery and total hair coverage monitored

13 FY 03 Areas of Review FY 03 Areas of Review Perioperative environmental evaluation Perioperative environmental evaluation Overall maintenance schedule for OR Overall maintenance schedule for OR HVAC – filters and calibration of system HVAC – filters and calibration of system Laminar flow in all operating rooms Laminar flow in all operating rooms Air quality & exchanges Air quality & exchanges Floor cleaning procedures Floor cleaning procedures Autoclave maintenance, cleaning and other procedures Autoclave maintenance, cleaning and other procedures

14 CSS: Orthopedic Surgical Instruments CSS: Orthopedic Surgical Instruments Inspection of Orthopedic Instruments Inspection of Orthopedic Instruments Lumens, grooves, sorting, hand cleaning, disassembly required – massive kits Lumens, grooves, sorting, hand cleaning, disassembly required – massive kits Many instruments cannot be disassembled Many instruments cannot be disassembled Company contracted – disassemble and bead blast the material coagulated and hardened within lumens Company contracted – disassemble and bead blast the material coagulated and hardened within lumens Instituted better pre-soaking and rinsing of tissue and blood from the instruments in the operating room before decontamination Instituted better pre-soaking and rinsing of tissue and blood from the instruments in the operating room before decontamination

15 Operating Room Operating Room Observed terminal cleaning procedures with night shift – what do they really do at night? Observed terminal cleaning procedures with night shift – what do they really do at night? Upgraded OR facilities – new floors, fixed walls, paint, mats Upgraded OR facilities – new floors, fixed walls, paint, mats Upgraded HVAC system - installed visual system (ball check valves) for air pressure in laminar flow rooms Upgraded HVAC system - installed visual system (ball check valves) for air pressure in laminar flow rooms Replaced HVAC HEPA filters Replaced HVAC HEPA filters

16 Operating Room Environmental safety rounds Environmental safety rounds OR staff IC in-services OR staff IC in-services Implement SCIP core measures: Implement SCIP core measures: warming patient warming patient surgical prophylaxis surgical prophylaxis hair clippers hair clippers increased oxygen increased oxygen

17 Infection Control: Established a weekly cross-check system of patients identified with resistant organisms (MRSA/VRE) and the OR Schedule Infection Control: Established a weekly cross-check system of patients identified with resistant organisms (MRSA/VRE) and the OR Schedule Send a weekly from Infection Control to: Send a weekly from Infection Control to: Presurgical Holding Unit Presurgical Holding Unit OR Surgical Scheduling OR Surgical Scheduling Patient Access Patient Access Operating Room Operating Room Prescreening Unit (PASU) Prescreening Unit (PASU) PACU PACU Master list of MRSA/VRE positive patients accessed on-line as a “live” file Master list of MRSA/VRE positive patients accessed on-line as a “live” file Operating Room

18 FY05 Operating Room FY05 Operating Room Ultrasonic scrub of all movable carts, tables, poles and equipment Ultrasonic scrub of all movable carts, tables, poles and equipment 1500 pieces of movable equipment were cleaned 1500 pieces of movable equipment were cleaned from OR, radiology and nursing units Cost:~$20,000 Cost:~$20,000 Now done annually Now done annually Spencer M, Anderson P, Creamer A. The E=MC2 Project: Environment = Maintaining Cleanliness, A Multidisciplinary Approach To Establish a Routine Cleaning Schedule for Medical Equipment. Abstract. American Journal of Infection Control. APIC 2005:33:5 E139-eoa.

19 Environmental Upgrades Environmental Upgrades Upgraded all OR rooms to laminar flow Upgraded all OR rooms to laminar flow Closed the OR over the holidays - entire cleaning of the inner core and rooms Closed the OR over the holidays - entire cleaning of the inner core and rooms Cleaned and renovated every nursing unit over 2-yr period Cleaned and renovated every nursing unit over 2-yr period

20 Hand Hygiene Educational Program FY03-FY06 Make it Fun, Consistent and Reinforced

Infection Control – Educational Foundation: Social Learning Theory Role Modeling (A.Bandura) Role Modeling (A.Bandura) Self-Efficacy(A.Bandura) Self-Efficacy(A.Bandura) Reinforcement(BF Skinner) Reinforcement(BF Skinner) Contracting(BF Skinner) Contracting(BF Skinner) Reciprocity(BF Skinner) Reciprocity(BF Skinner)

Infection Control Liaisons Unit- and Department-based liaisons Unit- and Department-based liaisons Role Models and Responsibilities enhance self-efficacy Role Models and Responsibilities enhance self-efficacy Participate in educational activities Participate in educational activities Hand hygiene observations Hand hygiene observations Precaution Carts and direct care observations Precaution Carts and direct care observations Communicate information to staff Communicate information to staff Assist in implementing practice change Assist in implementing practice change “Call-out” breaks in techniques “Call-out” breaks in techniques Attend monthly meetings Attend monthly meetings Contribute to an annual “Bug Beat Fair” Contribute to an annual “Bug Beat Fair” Participate in Performance Improvement Studies Participate in Performance Improvement Studies Clinical ladder for professional advancement Clinical ladder for professional advancement National Association of Orthopedic Nurses, May 2006 Poster Presentation: The Bug Beat Fair: An Innovative Infection Control Educational Campaign in An Orthopedic Specialty Hospital

23 FY03 Got Soap? Engage the Staff Engaged the OR staff in a Got Soap? Campaign Engaged the OR staff in a Got Soap? Campaign OR Nurses OR Nurses Surgeons Surgeons Administration Administration

24 Glo-Germ “Bug Beat” Fair Contact Plates Glo-Germ “Bug Beat” Fair Contact Plates

25 November 05 November 05 “Partners in Hand Hygiene” January 06 January 06 “Let it S.N.O.W.” Stop Nosocomial Organisms by Washing April 06 April 06 “Do the H.O.P.” Hand washing Offers Protection

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27 Let Us Always Use Let Us Always Use Good Hand Hygiene Good Hand Hygiene Cafeteria Cruise Ship Cafeteria Cruise Ship Alcohol hand rub to Alcohol hand rub to enter cafeteria Posters – Engage the Staff Posters – Engage the Staff Hawaiian music and food Hawaiian music and food Raffle table and Raffle table and candy distributed candy distributed

28 Games and prizes for everyone, raffles, dancing, candy 16 poster displays: Admitting Admitting Surgical Services Surgical Services Micro Lab Micro Lab EVS, Transport EVS, Transport Nursing Units Nursing Units

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34 Hand Hygiene Data

35 Direct Observations of Hand Hygiene During FY07-FY08

36 Environment of Care

37 Cleaning the Environment Cleaning the Environment Cleaning schedules for departments in Patient Care Services Cleaning schedules for departments in Patient Care Services Single-use micro fiber mop instead of buckets – OR and patient rooms Single-use micro fiber mop instead of buckets – OR and patient rooms EVS daily check sheet for room cleaning and precaution cases EVS daily check sheet for room cleaning and precaution cases

38 Focus: Environmental Services Focus: Environmental Services Disinfectant handling procedures – freshly prepared disinfectant dated weekly Disinfectant handling procedures – freshly prepared disinfectant dated weekly Silver Disinfectant Spray that Silver Disinfectant Spray that kills organisms up to 24 hr on surfaces Cubicle-curtain change policy –after each precaution discharge Cubicle-curtain change policy –after each precaution discharge 6 months on nursing unit 6 months on nursing unit 3 months - ICU and Ambulatory Care 3 months - ICU and Ambulatory Care

39 Focus: The Patient as a Source Risk factors leading to colonization and infection

40 Patient Risk Factors Fact: High rate of overweight or obese patients among those who developed infections Fact: High rate of overweight or obese patients among those who developed infections Fact: Glycemic control in diabetics and pre-diabetics can impact surgical outcomes and the potential for infection Fact: Glycemic control in diabetics and pre-diabetics can impact surgical outcomes and the potential for infection Fact: Poor patient hygiene and nutrition can impact surgical outcomes Fact: Poor patient hygiene and nutrition can impact surgical outcomes

41 Obesity and Surgical Incision Incision collects fluid – serum, blood – growth medium for organisms Incision collects fluid – serum, blood – growth medium for organisms Spine incisions – close to the buttocks Spine incisions – close to the buttocks Perspiration – diaphoresis Perspiration – diaphoresis Body fluid contamination from bedpans/commodes Body fluid contamination from bedpans/commodes Friction and sliding – skin tears and blisters Friction and sliding – skin tears and blisters Itchy skin – due to pain medications – skin breakdown Itchy skin – due to pain medications – skin breakdown

42 Why Higher Rates? Infection Formula Infection = inoculum size (number) x virulence of organism resistance of the host resistance of the host Infection Likely: small dose of MRSA x high virulence small dose of MRSA x high virulence morbidly obese, diabetic, smoker, ASA > 3, implant surgery & rehab morbidly obese, diabetic, smoker, ASA > 3, implant surgery & rehab Infection Not As Likely: large dose of Coagulase negative staph x low virulence large dose of Coagulase negative staph x low virulence healthy adult, normal weight, ASA < 2, nonsmoker, orthopedic surgery healthy adult, normal weight, ASA < 2, nonsmoker, orthopedic surgery Important to stratify and benchmark data

43 Control Measures to reduce surgical site infections

44 Surgical Incise Drapes Continued use of Iodophor- impregnated incise barrier drape Cost: > $60,000/year Continued use of Iodophor- impregnated incise barrier drape Cost: > $60,000/year No data to support these drapes reduce SSI No data to support these drapes reduce SSI Surgeon preference based on adhesion to skin Surgeon preference based on adhesion to skin

45 Bacitracin/Polymixin Irrigation Feb stopped routine use of Bacitracin/Polymixin Irrigation Feb stopped routine use of Bacitracin/Polymixin Irrigation Cost: > $110,000/year Cost: > $110,000/year Limited use for revisions, allografts and infected cases (irrigation and debridements) Limited use for revisions, allografts and infected cases (irrigation and debridements)

46 Surgical Infection Prevention Silver-coated latex urinary catheters Silver-coated latex urinary catheters Intent to reduce UTIs postoperatively Intent to reduce UTIs postoperatively Leave in for 24 hr to prevent urinary retention Leave in for 24 hr to prevent urinary retention No Bactrim prophylaxis post-op No Bactrim prophylaxis post-op

47 Skin Issues in Orthopedic Surgery

48 Incisional Adhesives Eliminates blood-stained Steri-Strips™ Eliminates blood-stained Steri-Strips™ Incisions may be closed faster and more Incisions may be closed faster and more securely than with regular stitches No need to have stitches removed No need to have stitches removed Forms a strong, flexible bond and protective Forms a strong, flexible bond and protective barrier for incision Seals out common infection-causing bacteria, including certain Staph, Pseudomonas and E coli Seals out common infection-causing bacteria, including certain Staph, Pseudomonas and E coli Patient can shower or bathe - disappears naturally Patient can shower or bathe - disappears naturally Bandages and dressings are usually not needed – therefore incision can be visually assessed Bandages and dressings are usually not needed – therefore incision can be visually assessed Steri-Strips™ can be applied over it to prevent dehiscence Steri-Strips™ can be applied over it to prevent dehiscence

Primary Dressing - Silver If incisional adhesive not used – we recommend the use of a silver primary dressing for duration of hospitalization If incisional adhesive not used – we recommend the use of a silver primary dressing for duration of hospitalization Increased fluid absorbency Increased fluid absorbency Can be covered by a transparent dressing to protect incision from exogenous contamination Can be covered by a transparent dressing to protect incision from exogenous contamination 50% reduction in Staph aureus and MRSA-causing spine infections during the year-long evaluation 50% reduction in Staph aureus and MRSA-causing spine infections during the year-long evaluation NAON – May, 2006 The Use of A Silver Gauze Dressing in Spine Surgery to Reduce The Incidence of MRSA Surgical Site Infections M. Spencer, RN, M.Ed, B. Perfetuo, RN, J. Beaulieu, RN, K. Larsen, PA, M. Leach, RN, J. Head, RN., R. Banco, MD.

Antimicrobial Sutures In July, 2005 – implemented use of antibacterial sutures for a full year evaluation In July, 2005 – implemented use of antibacterial sutures for a full year evaluation At the end of the trial period: 45% reduction in surgical site infections caused by Staph aureus and MRSA Reduction in total joint infections during trial period Manuscript in preparation

51 Antibacterial Suture Staph aureus Culture Plate Study Antibacterial Suture Staph aureus Culture Plate Study A pure culture MacFarland Broth - of Staph aureus was prepared A pure culture MacFarland Broth - of Staph aureus was prepared A coated antibacterial suture was aseptically cut and planted on the plate and incubated for 24 hrs A coated antibacterial suture was aseptically cut and planted on the plate and incubated for 24 hrs Photo #1 shows zone of inhibition Photo #1 shows zone of inhibition at day 5 Photo # 2 zone of inhibition at day 10 in plate on left. Plate on right is non-coated suture. Photo # 2 zone of inhibition at day 10 in plate on left. Plate on right is non-coated suture.

Articles Related To Antibacterial Sutures Rothenburger S, Spangler D, Bhende S, Burkley D. In vitro antimicrobial evaluation of Coated VICRYL* Plus Antibacterial (polyglactin 910) Suture (coated polyglactin 910 with triclosan) using zone of inhibition assays. Surgical Infections 2002;3 Suppl 1:S79-S87. Rothenburger S, Spangler D, Bhende S, Burkley D. In vitro antimicrobial evaluation of Coated VICRYL* Plus Antibacterial (polyglactin 910) Suture (coated polyglactin 910 with triclosan) using zone of inhibition assays. Surgical Infections 2002;3 Suppl 1:S79-S87. Ford HR. Jones P. Gaines B. Reblock K. Simpkins DL. Intraoperative handling and wound healing: controlled clinical trial comparing Coated VICRYL Plus Suture. Surgical Infections 6(3):313-21, Ford HR. Jones P. Gaines B. Reblock K. Simpkins DL. Intraoperative handling and wound healing: controlled clinical trial comparing Coated VICRYL Plus Suture. Surgical Infections 6(3):313-21, Edmiston CE. Seabrook GR. Goheen MP. Krepel CJ. Johnson CP. Lewis BD. Brown KR. Towne JB. Bacterial adherence to surgical sutures: can antibacterial-coated sutures reduce the risk of microbial contamination? Journal of the American College of Surgeons 203(4):481-9, Oct Edmiston CE. Seabrook GR. Goheen MP. Krepel CJ. Johnson CP. Lewis BD. Brown KR. Towne JB. Bacterial adherence to surgical sutures: can antibacterial-coated sutures reduce the risk of microbial contamination? Journal of the American College of Surgeons 203(4):481-9, Oct Go´mez-Alonso A, F.J. Garcı´a-Criado, F.C. Parren˜o-Manchado,J.E. Garcı´a-Sa´nchez, E. Garcı´a-Sa´nchez, A. Parren˜o-Manchado,Y. Zambrano-Cuadrado. A Study of the efficacy of Coated VICRYL Plus Suture in two animal models of general surgery Journal of Infection (2006). Go´mez-Alonso A, F.J. Garcı´a-Criado, F.C. Parren˜o-Manchado,J.E. Garcı´a-Sa´nchez, E. Garcı´a-Sa´nchez, A. Parren˜o-Manchado,Y. Zambrano-Cuadrado. A Study of the efficacy of Coated VICRYL Plus Suture in two animal models of general surgery Journal of Infection (2006).

53 MRSA and Staph aureus Eradication Program Prescreening Process Topical Decolonization Protocol Vancomycin for MRSA

54 February 2006 NEBH Internal Anonymous Culture Study 133 patients Obtained nasal cultures Purpose: to determine pre-op MRSA and MSSA colonization rates Results: 38 – Staph aureus (29%) *5 - MRSA ( 4%) *5 - MRSA ( 4%) *all undiagnosed and no precautions used in OR or post-op nursing unit

55 MRSA/MSSA Eradication Program Pilot conducted from July – August, then full implementation September 1, 2006 Pilot conducted from July – August, then full implementation September 1, hour rapid MRSA test equipment 2 hour rapid MRSA test equipment Estimated cost: ~$400,000/first year – included two FTEs and new rapid testing equipment Estimated cost: ~$400,000/first year – included two FTEs and new rapid testing equipment

56 Cost of the MRSA/MSSA Program ~$400,000 implementation cost: ~$400,000 implementation cost: Two full-time positions: Micro and PASU Two full-time positions: Micro and PASU ~$60,000 Polymerase Chain Reaction Equipment ~$60,000 Polymerase Chain Reaction Equipment ~$40.00/test x ~6,000 = $240,000 ~$40.00/test x ~6,000 = $240,000 Reimbursement code: Reimbursement code: MRSA Screen with CPT code ( ) MRSA Screen with CPT code ( )

MRSA Reimbursement Code CPT CodeCharge MedicareBCOther PPO Rule Out Cx $28.00 $9.26$14.37 $15-$ MRSA by PCR $ $36.39 $50.15 $61-$99

58 Treatment Protocol Treatment Protocol 5-day application of intranasal 2% mupirocin - applied twice daily - for MRSA and MSSA positive patients. Daily body wash with 4% chlorhexidine MRSA Patients - Vancomycin surgical prophylaxis. Re-screen positive MRSA before surgery

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Initiative - Chlorhexidine  Chlorhexidine pre-op showers (night before, morning of)  2% CHG/70% alcohol skin preparation (tinted orange)  Antimicrobial dressing material for primary and secondary dressings

61 What were the outcomes?

62 MRSA/MSSA Eradication Program Results From July 17, 2006 through September 30, ,345 patients screened 3268 ( 24%) positive for Staph aureus 3268 ( 24%) positive for Staph aureus 601 (4.5%) positive for MRSA 601 (4.5%) positive for MRSA Repeat nasal screens on MRSA patients revealed 78% eradication Repeat nasal screens on MRSA patients revealed 78% eradication

63 Time Period Inpatient surgeries Surgical Infections Infec. Rate FY06 10/01/05-07/16/ * % FY07 07/17/06-09/30/ % FY08 10/01/07-09/30/ % * historical controls + screened inpatient surgeries MRSA and Staph aureus Infection Rates

64 Surveillance Data

65 NEBH SSI Rates

Risk Analysis Spine Service rates Spine Service rates MRSA and SSI – community- acquired strains MRSA and SSI – community- acquired strains Laminectomy rates – ? use of steroids (DepoMedrol ® ) in surgical incision Laminectomy rates – ? use of steroids (DepoMedrol ® ) in surgical incision Total Knee Infection Rates – ? Due to injection of pain meds in joints Total Knee Infection Rates – ? Due to injection of pain meds in joints 2008 – Clostridium difficile Infection 2008 – Clostridium difficile Infection 66

67 Potential Savings Orthopedic Surigcal Site Infections Cost: ~ $25,000/each FY03 – 63/8837 cases (0.7%) 1.6 million FY04 – 60/9669 cases (0.6%) 1.5 million FY05 – 49/9216 cases (0.5%) 1.2 million FY06 – 46/8986 cases (0.5%)1.1 million FY /9027 cases (0.4%) $975,000 FY /8884 cases (0.4%) $925,000

68 Tools for Success Senior leadership and Board of Trustees involvement – “lead the effort” Senior leadership and Board of Trustees involvement – “lead the effort” Structured program with clearly defined goal of zero tolerance for HAIs Structured program with clearly defined goal of zero tolerance for HAIs Communication – effective and consistent Communication – effective and consistent Ongoing and creative education Ongoing and creative education Financial support to Infection Control Financial support to Infection Control

THANK YOU We are all in this together!