Inter Regional General Surgery Meeting April

11, 2010 Surgical Site Infection

Prevention Bundle and Plus Measures

Steve Parodi, MD, Chair KP NCal Regional Infectious Disease Chiefs, Chief ID Vallejo, CA stephen.m.parodi@kp.org

Sue Barnes, RN, CIC, National Leader, KP Infection Prevention and Control - National Office - Oakland, CA sue.barnes@kp.org

Overview

Bundle vs. Plus Measures and supporting evidence

Success stories for top 3 Plus Measures Definitions, detection and reporting

(including NSQIP vs. NHSN definitions) Public reporting mandates by region PAB guidelines supporting infection

prevention

Bundle Measures vs. Plus Measures

• The Care Bundle concept created in 2002 by VA/IHI when vent bundle was developed

• Per IHI definition a bundle = 3-5 practices designed to be performed all at once every time – each is based on RCTs

• Plus Measures = prevention efforts supported by less than category 1 level evidence – see KP Plus Measures Toolkit (pg 7-9): http://kpnet.kp.org/qrrm/patient/infection/hot_topics/hot_topics.html

Success stories for top 3 Plus Measures1. Chlorhexidine impregnated bathing

cloths or showers pre-operatively2. Normothermia3. Dual agent skin prep – i.e. Chloraprep

or Duraprep

Med Centers performing all 3

Time since last SSI

Hospital 1 12 mo

Hospital 2 15 mo

Hospital 3 1 SSI in 30 months

Med Centers performing 2/3

Time since last SSI

Hospital 4 24 mo

Hospital 5 9 mo

Hospital 6 1 SSI in 15 months

Plus measures – SSI Prevention (in addition to SCIP

measures)1. ensure for ortho cases that pre op antibiotic is infused 20 minutes prior to tourniquet application.

2. 3rd party observation of surgical cases using standard IC checklist

3. cover staff hair (beard, chest, head); clip patient hair (and remove clipped hair) before entering OR; teach female patients no leg shaving for pre op total knee replacement

4. pre op antiseptic bathing – impregnated cloths vs. shower5. post op antiseptic dressings6. consider: 3 gms ancef pre op as standard at least for bariatric7. decolonization MRSA pre op high risk procedures8. antiseptic impregnated post op dressings

Microsoft Word Document

Revisiting the Preadmission (Preoperative) Shower

1. Conclusion: No evidence-based benefit

2. 6 sentinel studies – legitimate concerns• No routine standard of practice• Some individuals showered once, other

multiple times• Heterogeneous study population• No evidence of patient compliance

Cochrane Collaborative• Eyers PS, et al. Cochrane Database 2006;3: CD003073• Edwards et al.. Cochrane Database 2006;3: CD003949. pub 2

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Skin SitesSkin Sites

Left Left ElbowElbow

Right Right ElbowElbow

AbdominalAbdominal Left Left KneeKnee

Right Right KneeKnee

Pilot Data – Skin Concentration of 4% Chlorhexidine Gluconate (CHG) Following

Shower - “Evening” and “Morning” (N = 10)

MICMIC9090 = 4.8 ppm = 4.8 ppm

Note: 3 subject in “Evening” and 2 subjects in “Morning” groups recorded no CHG concentration at 1 or more skin sites

“Morning” Group (AM)”

CHG Shower

“Evening” Group (PM)”

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Skin SitesSkin Sites

Left Elbow

Right Elbow

Abdominal Left Knee

Right Knee

4% Chlorhexidine Gluconate (CHG) Shower -

Skin Surface Concentration (N=60)

MIC90 = 4.8 ppm

Group 2A “Morning (AM)”Group 3A

“Both (AM and PM)”

CHG Shower

Group 1A “Evening (PM)”

p p <<0.050.05NSNS

P<0.001P<0.001

Edmiston et al, J Am Coll Surg 2008;207:233-239

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Group 1B “Evening (PM)”Group 2B “Morning (AM)”

Right Elbow

Abdominal Left Knee

Right Knee

2% Chlorhexidine Gluconate (CHG) Impregnated Cloth Application – Skin

Surface Concentration (N = 60)

Group 3B

“Both (AM and PM)”

MIC90 = 4.8 ppm

CHG Cloth Application

p<0.05 p <0.001

Edmiston et al, J Am Coll Surg 2008;207:233-239

Efficacy of Preoperative CHG Wipes

Observational non-randomized use of 2% CHG impregnated cloths on orthopedic total joint patients - SSI Rates dropped 50.1% (3.2% to 1.6%)

Need randomized studies Need to make sure patients adhere to

protocol for application

Eiselt, Ortho Nurs 2009;28:141-5

A PROSPECTIVE, RANDOMIZED, MULTICENTER CLINICAL TRIAL OF 2% CHLORHEXIDINE GLUCONATE / 70%

ISOPROPYL ALCOHOL (Alc-CHG) VS POVIDONE-IODINE (PI) FOR PREVENTION OF SSI

• Patients > 18 years, undergoing clean/clean-contaminated procedures (gastrointestinal, thoracic, urologic and gynecologic)

• N = 820 surgical patients: 400 Alc-CHG vs. 420 PI :1 randomization

• Patients monitored for 30 days post-op• Overall rate of SSI was significantly reduced in Alc-CHG vs. PI

groups: 9.8 vs. 16.9, p<0.003• Significant difference (p<0.01) in superficial incisional site rate:

4.3% (A-CHG) v. 8.6% (PI) – rate for deep incisional 1% v. 3%• No significant difference for organ space infection• No significant adverse events noted during the study in either

group• Alc-CHG superior to PI in reducing the risk of SSI in

clean/clean-contaminated procedures

Dairouche, NEJM 2010;362:18-26

What to do about MRSA?Conflicting Studies Regarding Preop Screening

Large randomized crossover trial using universal screening of specialty v. general surgical patients for MRSA. MRSA patients received decolonization and periop vanco. No difference in SSI rates.

Smaller controlled trial screened patients, treated with decolonization and daily CHG baths. Excluded “simple procedures.” Reduced S. aureus SSI rates by 60%.

Screening generally restricted to more complex procedures (i.e. implants, CV surgery)

Harbath JAMA 2008;299:1149Bode NEJM 2010;362:9

Percent Serum/Tissue Concentrations Achieving Therapeutic levels at a 2 gm (N = 38) and 3 gm (N = 40) Perioperative Dosing

Regimen

2-gma 3-gmb

Organism N Serum Tissue N Serum Tissue

S. aureus 70 68.6% 27.1% 92 87.5% 68.5%

S. epidermidis 110 34.5% 10.9% 156 64.5% 49.6%

E. coli 85 75.3% 56.4% 101 92.4% 86.5%

Kl. pneumoniae 55 80% 65.4% 49 96.8% 90.4%

a period covering 2001-2003

b period covering 2006-2008aEdmiston et al, Surgery 2004;136:738-747bEdmiston et al., Submitted for publication 2009

Perioperative Antimicrobial Prophylaxis in Higher BMI (>40) Patients: Do We Achieve

Therapeutic Levels?

Evaluation of Antiseptic Activity of Triclosan-Coated Polyglactin 910 Suture at 24, 48, 72 and 96 Hours

Compared to Standard Polyglactin 910 Braided Suture

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S. aureus (105)MRSA

S. epidermidis (105) RP62A

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Non-coated polyglactin Non-coated polyglactin 910910

NS NS

24 hr VT24 hr VT

48 hr VT48 hr VT

72 hr VT72 hr VT

96 hr VT96 hr VT

N=10N=10

p<0.01

p<0.01

Edmiston et al, J Am Coll Surg 2006;203:481-489

Antimicrobial Suture (AMS) Wound Closure for Cerebrospinal Fluid Shunt Surgery: A

Prospective, Double-blinded, Randomized Controlled Trial

The shunt infection rate in the study group was 4.3%, while the infection rate was 21% in the control group (p = 0.038). There were no statistically significant differences in shunt infection risk factors between the groups. These results support the suggestion that the use of AMS for CSF shunt surgery wound closure is safe, effective, and associated with a reduced risk of postoperative shunt infection.

Rozzelle et al., J Neurosurgery 2008;2:111-117

Definitions: NSQIP vs. NHSN1. NSQIP Definition: Identifies by CPT code reports SSI data in 3 procedure categories combining various

procedures: general, vascular, colorectal uses O/E (observed/expected) ratios instead of

infections/procedures x 100 (rate) instead of infection rates2. NHSN Definition: categorized by wound severity: superficial, deep, or organ

space all surgical procedures reported separately rates are stratified by risk index 0 – 3: one point assigned for

each of the following: 1. Operation lasts for longer than 2 hrs 2. Contaminated or dirty/infected wound classification 3. ASA Classification of 3, 4 or 5.

Public reporting mandates by region1. NW ICU BSI, SSIs total knee and

CABG2. CO BSI in ICU, VAP, SSI in THA,

TKA, Hernia, CABG, and Vag hyst. 3. HAWAII no reporting required4. MAS MD - BSI in the ICU, SSI CABG,

hips and knees; VA - BSI; DC -MRSA, SCIP measures

5. GA no reporting at this time6. OH no reporting at this time7. NCAL/SCAL MRSA Bloodstream

Infections (BSIs), Clostridium difficile infections, VRE BSIs, Non-ICU Central line-associated BSIs not reported through NHSN, Deep or organ/space Surgical Site Infections not reported through NHSN, Orthopedic (total knee/hip), Cardiac (CABG), GI (colon resection), SCIP

PAB guidelines supporting infection prevention

Infusion of the first antimicrobial dose should begin within 60 minutes before the surgical incision

Infusion antibiotic completed 20 minutes prior to inflation of tourniquet for total knee

Discontinue 24 hours post operatively Adjust dose by weight Order set