Preventing Surgical Site Infections

Objectives Review microbiology basics of bacteria Review infection control measures for isolation patients Hand hygiene importance Surgical Site Infection(SSI) surveillance OR nurses role in SSI prevention Discuss cleaning and disinfecting

Staphylococcus aureus Gram-positive cocci, facultative anaerobe Frequently found as part of the normal skin flora and in nasal passages Most common species to cause Staph infections – successful at evading the immune system Often the cause of surgical site infections Spread of S. aureus is generally through human-to- human contact Your books page 50 You don’t have to memorize what’s aerobic or anaerobic but you should know what the surgeon wants from a wound culture and how to send it. According to the lab, a tissue specimen is always better than a swab. Keep sterile don’t leave the swab open too long.

Streptococcus Gram Positive, non-spore forming. Group A Strep common in necrotizing fasciitis. Part of normal skin flora. Most bacteria in the OR environment are shed from the skin of perioperative personnel. Normal flora, not resistant. Your NF patient may not be on any kind of precautions

Enterococcus spp. Gram positive cocci, often occur in pairs or short chains, facultative anaerobes Common organisms in the GI tract High level of intrinsic antibiotic resistance Found in SSI, UTI, bacterial endocarditis & septicemia. Vancomycin-Resistant Enterococcus (VRE) Infections with this one are serious and hard to get rid of.

Escherichia coli Gram negative rod, facultative anaerobe Harmless strains are part of GI flora Responsible for ~90% of UTIs

Mycobacteruim Tuberculosis Non spore-forming bacillis Can infect almost any tissue including skin, bone, lymph nodes, intestine. Spread through upper respiratory tract and dispersed through the body by macrophages. Patients without active infection are not infectious What kind of precaution are these patients on? More common in AK

Multi-Drug Resistant Organisms Gain resistance to antibiotics by: Mutations Sharing resistance genes Inherent resistance Use ABX appropriately, give on time. Even if floor med. Document

Vancomycin-Resistant Enterococcus (VRE) VRE can be carried by healthy people The most commonly transmitted by the contaminated hands of healthcare workers Can remain viable in the environment for extended periods - Resistant to desiccation and temperature extremes Hard to get rid of able to survive on surfaces WE all talk about MRSA but its VRE Patients actively colonized or infected must be in contact precautions

Patients actively colonized or infected must be in contact precautions MRSA Any strain of Staphylococcus aureus that has developed resistance to beta-lactam antibiotics Does not mean it is more virulent, however it is more difficult to treat with standard antibiotics Healthcare provider-to-patient transfer is common, especially when hand hygiene is poor Patients actively colonized or infected must be in contact precautions

Colonized patients represent the major reservoir of MRSA Infected Colonized Countries that actively seek out and isolate MRSA colonized patients have very low rates of MRSA transmission

Creutzfeldt-Jakob Disease Transmissible spongiform Encephalopathy Disease causing organism is prion Can be hereditary or occur spontaneously 1% of cases are transmitted person-person, requires CNS tissue contact for transmission. Resistant to conventional heat and chemical methods of sterilization. Special sterilization practices or use of disposable instruments a must. Prion = infectious proteins Some places use disposable stuff for any brain biopsy of unknown etiology. You wont remember everything you need to know when it comes in 2 to 8 years what you really need to know is how to find out what to do.

Do all health care workers “carry” MRSA? 4-6% of HCW colonized w/MRSA (2014) As opposed to about 1% of general population Not colonized does not mean you can’t transmit MRSA Nor does it mean you cannot become colonized http://bmcinfectdis.biomedcentral.com/articles/10.1186/1471-2334-14-363 You will hear people say we’re all colonized as a way of dismissing tedious precautions

Chain of Infection Causative Agent Susceptible Host MRSA Reservoir Surgical, dialysis, cancer patient Skin, wound, urine Portal of Entry Portal of Exit Central line, wound, ventilator Secretions, cough, drains Mode of Transmission Hands, equipment

The body’s defenses are compromised during surgery External barriers- skin Inflammatory response Immune response Compromised by surgery and compromised by illness and injury leading to surgery

Environment of Care An OR is more than just a room where everyone has a cool hat. Surgical department is semi-restricted Scrubs, Hat, Booties An open OR is a restricted Environment scrubs, hat, mask, and Booties Temp 68-73 degrees Humidity 30-60% Smooth surfaces, easily wiped clean Face shield a good idea put not part of restricted environment attire. At least 30 to prevent static electricity and no more than 60 to prevent condensation.

Environment of Care ctd. AIRFLOW OR suites arranged around a sterile core Airflow from core to rooms to hallways (positive air pressure in OR relative to hallways) 15 air exchanges per hour Nurse controls movement through and around the OR Best Practice: enter through core when open. Air flows from the top down, don’t block the exits with your garbage bags. And try to stir things up too much “excessive movement” causes pathogens to fly about the room. Keep doors and pass-through cabinets closed Similar to the protective environment you would have for neutropenic and immunocompromised patients cause patients with their bodies open are compromised.

Transmission-Based Precautions Contact - Spread through direct or indirect contact - MRSA, ESBL, VRE, C. diff., RSV, Shingles - Place signs on OR doors, notify housekeeping personnel. -Don’t forget PACU -Terminal clean after case. “When transport or movement in any healthcare setting is necessary, ensure that infected or colonized areas of the patient's body are contained and covered.”- CDC Contact- lets talk about reality VS Expectation. -Where do you chart when your pt is on contact? Things that can live for a long time on surfaces or are hard to get rid of. Wear a gown/gloves when interacting with the patient. http://www.cdc.gov/hicpac/2007IP/2007ip_part4.html

Transmission-Based Precautions Droplet - Airborne particles larger than 5 microns do not remain suspended in the air for long periods - 3 foot rule, mask patient (unless intubated) - Bacterial meningitis, influenza, B. pertussis -Use door signs and terminal clean room -Transport same as contact precaution but with surgical mask on the patient. -Don’t forget PACU Change your scrubs

Airborne Precautions If an OR must be positively pressurized to protect our patients, how do we handle TB patients? Gold Standard is a negative pressure anteroom If that isn’t available… Intubate/Extubate in a negative pressure room and transport using a ventilator with HEPA filter. What if it’s an Airway case? Wear N95 mask while in the OR Keep OR closed for min 28 minutes following case Keep doors closed during case Supplemental air cleaning with portable HEPA Don’t forget… What do we know about airborne precautions? Don’t forget PACU, if no neg pressure PACU recover the pt in the OR ALSO - make cases the last case of the day, when the others are done. Terminal clean, change clothing etc. Transport the patient wearing a surgical mask. Go Directly to OR- dunno where else you’d take this patient All of these still leave questions: What about going to the PACU? What if I need something..? do what you have to do no risk is zero but on breech does not make others OK What about TB in the wound? OR procedures are considered aerosolizing. Boss says talk with your team, you can always treat something like its airborne if that makes you happy.

Contact Enteric -Hand washing on room egress with soap and water Contact Enteric -Hand washing on room egress with soap and water. May use alcohol based hand sanitizer on entry. -All environmental cleaning to be done with bleach based products. -Must be transferred or discharged and room terminally cleaned with bleach before resolution of contact enteric precautions. -C diff, norovirus.

Hand Hygiene Hands contaminated with transient bacteria are a primary means for transmission leading to infection. Transient flora are microorganisms that colonize the superficial layers of the skin. These are acquired by HCW while caring for patients and from coming into contact with contaminated surfaces where patients reside. Hands with broken skin are more susceptible to becoming colonized with transient bacteria, including MDROs. An outbreak involved a cardiac surgeon’s infected fingernail. When cultured, it grew Psuedomonas aeruginos. Two patients treated by the surgeon developed a surgical site infection with the same strain of P. aueruginosa. (AORN Guidelines 2012) You’d think it wouldn’t be that big a deal esp with 2 layers of surgical gloves but it is, gloves roll bacteria happens. Its all about risk mitigation

Hand Hygiene Short fingernails are a must. Longer nails have increased bacterial load, are harder to keep clean. No Artificial nails of any kind No fingernail polish, gel nails or overlays. Chipped nail polish harbor bacteria and can cause gloves to rip. No rings! There is a strong link between wearing rings and hand contamination. (AORN Guidelines, 2012)

Hand Hygiene Skin irritation, dermatitis from frequent hand washing is common. Use plenty of lotion to keep skin intact. ONLY use hospital provided lotion. If you have cuts, abrasions, weeping dermatitis on exposed skin you should NOT be providing direct patient care. You are at risk for acquiring and transmitting infection. Lets talk about real world vs ideals.

Surgical Hand Antisepsis Persistent antimicrobial activity is important Alcohol has no persistent effect, CHG is most effective Remove all jewelry Remove all debris from under fingernails under running water Scrub hands and forearms for the recommended time (3-5 minutes, depending on product guidelines) Scrubs longer than the manufacturers guidelines are unnecessary

Partnering to Heal | HHS.gov Hand hygiene the single most important measure to prevent the transmission of infection Partnering to Heal | HHS.gov

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Surgical Site Infections (SSIs) Always have allograft available anyway Surgical Site Infections (SSIs)

Surgical Site Infections… Account for14-16% of all nosocomial infections among hospitalized patients Account for 38% of nosocomial infections among surgical patients Occur in 2-5% of extra-abdominal operations, and 20% of intra- abdominal operations Cost an average of $25,546 per affected patient Are preventable! Remember the pre-op abx recommendations from Tuesday. Colon stuff was on there.

Patient Factors Morbid obesity Nicotine use Steroid use Malnutrition Diabetes Morbid obesity Nicotine use Steroid use Malnutrition Prolonged preoperative hospital stay Comorbidities Perioperative transfusion Immunosuppressive therapy, neutropenia

Surgical Site Infection Surveillance Total knee replacements Total hip replacements Laminectomy Fusion All cardiac with open chest C-section Colectomy Abdominal hysterectomy These are procedures who rate of infection is nationally monitored. If these look familiar its cause they are almost the exact same set at the ones with pre-op antibiotic recommendations

Defining Surgical Site Infections

Superficial Incisional SSI Occurs within 30 days of surgery Involves skin or subcutaneous tissue Patient has at least one of the following: Purulent Drainage Identified organisms Pain/tenderness, edema, redness or heat Opened by the surgeon , and culture positive or not cultured Diagnosed by the surgeon or attending physician

Deep Incisional SSI Occurs within 30 or 90 days after surgical procedure AND Involves deep soft tissues (fascial and muscle layers) Patient has at least one of the following: Purulent drainage Incision spontaneously dehisces or is opened by surgeon and is culture positive or not cultured, and the patient has fever or pain/tenderness Abscess found on direct exam, during re-op, or by examination by histopathology or radiology Diagnosis by surgeon or attending physician

Organ/Space SSI Occurs within 30-90days of surgery Involves any part of the body (excluding skin, fascia, or muscle layers) One of the following symptoms: Purulent drainage Incision spontaneously dehisces or is opened by surgeon and is culture positive or not cultured, and the patient has fever or pain/tenderness Abscess found on direct exam, during re-op, or by examination by histopathology or radiology Diagnosis by surgeon or attending physician Joint Capsule is considered a space. SSI up to 1 year post op

And meets at least one criteria for site below. Code Site BONE Osteomyelitis MED Mediastinitis BRST Breast abscess or mastitis MEN Meningitis or ventriculitis CARD Myocarditis or pericarditis ORAL Oral cavity (mouth, tongue, or gums) DISC Disc space OUTI Other infections of the urinary tract EAR Ear, mastoid OREP Other infections of the male or female reproductive tract EMET Endometritis ENDO Endocarditis EYE Eye, other than conjunctivitis PJI Periprosthetic Joint Infection GIT GI tract SINU Sinusitis HEP Hepatitis SA Spinal abscess without meningitis JNT Joint or bursa IAB Intraabdominal, not specified UR Upper respiratory tract IC Intracranial, brain abscess or dura VASC Arterial or venous infection LUNG Other infections of the respiratory tract VCUF Vaginal cuff

Preoperative Prevention Strategies SCIP (Surgical Care Improvement Project) Measures to Prevent Infections: FYI….100% compliance with SCIP measures is essential for complete re-imbursement by CMS Administer the appropriate prophylactic antibiotic within one hour prior to surgical incision for included surgeries CABG, Cardiac or Vascular procedures Hip/Knee Arthroplasty Colon Hysterectomy Discontinue prophylactic antibiotics within 24 hr of surgery end time (48hours for cardiac patients).

Perioperative Prevention Strategies SCIP (Surgical Care Improvement Project) Measures to Prevent Infections: Glucose Control Control serum glucose in cardiac surgery patients < 200mg/dl @ 0600 post-operative days 1 and 2 Hair Removal Use national guideline approved method for surgical site hair removal Avoid shaving with razors Use clippers

Preoperative Prevention Strategies SCIP (Surgical Care Improvement Project) Measures to Prevent Infections: Ensuring Normothermia Perioperative hypothermia occurs when a patient’s core body temp falls below 36 C and is associated with increased SSIs, longer hospital stays, and other negative outcomes Use warming devices to ensure patient temp >36 C in or near the OR and upon arrival to PACU Foley Catheter Removal Day of surgery is traditionally zero Urinary catheter removed on Postoperative Day 1 (POD 1) or Postoperative Day 2 (POD 2) with day of surgery being day one

Cleaning and Disinfecting “The responsibility for verifying a clean surgical environment rests with perioperative nurses.” OR RN should assess the environment frequently for cleanliness and take action where needed All flat surfaces should be damp dusted before the first scheduled procedure of the day OR suites should be cleaned after each procedure Damaged or worn coverings need to be discarded and replaced Patient transport devices, including straps and attachments need to be cleaned after each use

Remember that you are the patient’s advocate Remember that you are the patient’s advocate! It’s your job to ensure the team is adhering to aseptic practices, and that you safeguard your patients privacy and ensure their safety.

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