1. Preventing Surgical Site Infections

2. 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

3. 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.

4. 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

5. 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.

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

7. 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

8. 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

10. 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

11. 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

12. 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

13. 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.

14. 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
You will hear people say we’re all colonized as a way of dismissing tedious precautions

15. 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

16. 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

17. 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 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.

18. 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.

19. 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.

20. 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

21. 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.

23. 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.

24. 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

25. 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)

26. 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.

27. 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

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

29. Break?

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

31. 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.

32. 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

33. 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

34. Defining Surgical Site Infections

36. 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

37. 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

38. 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

39. 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

40. 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).

41. Perioperative Prevention Strategies
SCIP (Surgical Care Improvement Project)
Measures to Prevent Infections:
Glucose Control
Control serum glucose in cardiac surgery patients < 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

42. 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

43. 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

44. 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.

45. ?