Preventing Surgical Site Infections with the SHEA Bundle

Where we are vs.

Where we hope to be

San Diego APIC Chapter September, 2016

Angela Vassallo, MPH, MS, CIC, FAPIC Director, Infection Prevention/Epidemiology Providence Saint John’s Health Center, Santa Monica, CA President-Elect, CA APIC

Today…

• Changes in SSI Surveillance in the past 5 years

• Infection Prevention “projects” in the OR • Surgical Attire excitement according to AORN and ACS • OR cleaning and disinfection

• NHSN/CDC criteria for SSI’s and meaningful use of data • The SSI Prevention Bundle (SHEA, 2014)

Also, I have no conflicts of interest! 2

Learning Objectives

1. Understand the components of the SSI Prevention Bundle

2. Determine where your organization is in implementing the SSI Prevention Bundle

3. Identify key opportunities for improvement in your program’s SSI Prevention Bundle process

SSI Surveillance changes

over the past 5 years…

Old School…

• Surgery Committee presentations with SSIs as Rates

• Monthly letters to surgeons to return with SSI info

• Little involvement with Surgery Staff in SSI Prevention

• Surgical prep: Chloraprep vs Betadine

• Surgical denominator data

• Excel spreadsheet from the OR Director

• Download from Ace (Remember that?)

• Targeted SSI surveillance based upon committee recommendations

• Hips/Knees

• Laminectomies

• C-Sections

New school…

• SSI data is now public through CDPH: https://www.cdph.ca.gov/programs/hai/Pages/SurgicalSiteInfections-Report.aspx • Letter to Surgeons? Are they aware of their public data?

• 2011 CDPH mandate to report SSIs from 29 selected procedures through NHSN • Was IP staffing increased at this time to account for this new

reporting mandate?

• Did your facility switch from reporting Rates to SIRs in committees? • How long did it take to educate everyone?

• NHSN SSI definition changes in 2013 • IP no longer tracks implantables for one year. Really?

• 30 to 90 days max? What?

• Surgical Denominator data is no longer just a number • 32 data points per surgical patient with specific directions for extra fields

to be left empty on an Excel spreadsheet

• And, you can still have “BAD DATA” per NHSN!

Infection Prevention

involvement in the OR is multi-faceted.

SSI Prevention or NOT?

Hair

• Shaving vs. Clipping

• Where is this done – in Preop, Patient’s home, OR suite?

Skin Prep

• Betadine, Chloraprep, Duraprep, Merlin, etc.

Cleaning/Disinfection of the OR

• Contact time of disinfectants vs. room turn-over time

• Staff Certification (EVS staff vs. Surgical Tech staff)

• OR Environment Cleaning Toolkit (AORN and EcoLab)

• New technology: UV, Hydrogen Peroxide vapor/mist, ATP

• Who cleans the iPhones and iPads that are taken into the OR?

• What is your stance on personal bags in the OR (fabric vs hard surfaces vs plastic bags)?

SSI Prevention or NOT?

Sterile Processing • Dr. Rutala’s 14 Steps for assessing disease transmission after

breaches in disinfection and sterilization (www.disinfectionandsterilization.org)

• Biological Indicator monitoring

• What indicator is your SPD using and when (with each load, daily, weekly)?

• Is this data reported to the Infection Prevention Committee, the Surgery Committee or EOC?

• Flash vs. “Immediate Use” • Early release of implants?

• Does anyone ever drop things on the floor in the OR during a

procedure (accidentally, of course)? • Do they tell Infection Prevention about it when they do?

SSI Prevention or NOT?

• Hand Hygiene • Who monitors OR staff?

• Do the monitors understand flow in the OR?

• Do circulators gel in and gel out?

• Anesthesia • Does IP attend the Anesthesia Committee and vice versa?

• Sentinel Event 52: Safe injection practices • Any education done on this issue?

• Surgical Attire • Does OR leadership enforce a surgical attire policy?

• Do staff still wear cloth caps (under bouffants)?

• Do staff wear their own OR shoes and transport patients from OR to ICU?

• Do staff wear booties in the café over their OR shoes?

• Does staff wear jewelry?

• Do staff tuck in scrub tops and wear cover jackets?

• Temp and humidity monitoring • Does Engineering call OR and/or IP when out of range?

Surgical Attire

Rationale

“Although there is no direct link between

nonsterile surgical attire and the impact on

surgical site infections, it seems prudent to

minimize a patient’s exposure to a surgical team

member’s skin, mucous membranes, or hair.”

Braswell, M.L., Spruce, L. Implementing AORN Recommended Practices for Surgical Attire, AORN. (January 2012) 122-137. doi: 10.1016/j.aorn.2011.10.017

“It is recommended that perioperative personnel in the semi-restricted and restricted areas wear facility-approved, clean, freshly laundered, or disposable surgical attire, including shoes, head coverings, masks, jackets, and ID badges.

Perioperative personnel should change into surgical attire in designated dressing areas to decrease the possibility of cross-contamination and to assist with traffic control and…

should change back into street clothes if they need to leave the facility or travel between buildings to prevent contaminating the surgical attire through contact with the external environment.”

• Braswell, M.L., Spruce, L. Implementing AORN Recommended Practices for Surgical Attire, AORN. (January 2012) 122-137. doi: 10.1016/j.aorn.2011.10.017

Surgical Attire

America College of Surgeons August, 2016

“The ACS guidelines for appropriate attire are based on professionalism, common sense, decorum, and the available evidence. They are as follows: • Soiled scrubs and/or hats should be changed as soon as feasible and certainly prior to speaking with

family members after a surgical procedure. • Scrubs and hats worn during dirty or contaminated cases should be changed prior to subsequent cases

even if not visibly soiled. • Masks should not be worn dangling at any time. • Operating room (OR) scrubs should not be worn in the hospital facility outside of the OR area without a

clean lab coat or appropriate cover up over them. • OR scrubs should not be worn at any time outside of the hospital perimeter. • OR scrubs should be changed at least daily. • During invasive procedures, the mouth, nose, and hair (skull and face) should be covered to avoid

potential wound contamination. Large sideburns and ponytails should be covered or contained. There is no evidence that leaving ears, a limited amount of hair on the nape of the neck or a modest sideburn uncovered contributes to wound infections.

• Earrings and jewelry worn on the head or neck where they might fall into or contaminate the sterile field should all be removed or appropriately covered during procedures

• The ACS encourages clean appropriate professional attire (not scrubs) to be worn during all patient encounters outside of the OR.”

Retrieved on 8-17-16 from: https://www.facs.org/about-acs/statements/87-surgical-attire

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• “The skullcap is symbolic of the surgical profession. The skullcap can be worn when close to the totality of hair is covered by it and only a limited amount of hair on the nape of the neck or a modest sideburn remains uncovered. Like OR scrubs, cloth skull caps should be cleaned and changed daily. Paper skull caps should be disposed of daily and following every dirty or contaminated case. Religious beliefs regarding headwear should be respected without compromising patient safety.

• Many different health care providers (surgeons, anesthesiologists, CRNAs, laboratory technicians, aids, and so on) wear scrubs in the OR setting. The ACS strongly suggests that scrubs should not be worn outside the perimeter of the hospital by any health care provider. To facilitate enforcement of this guideline for OR personnel, the ACS suggests the adoption of distinctive, colored scrub suits for the operating room personnel.

• The ACS emphasizes patient quality and safety and prides itself on leading in an ever-changing and increasingly complex health care environment. As stewards of our profession, we must retain emphasis on key principles of our culture, including proper attire, since attention to such detail will help uphold the public perception of surgeons as highly trustworthy, attentive, professional, and compassionate.

• This statement will be published October 2016 in the Bulletin of the American College of Surgeons.”

Retrieved on 8-17-16 from: https://www.facs.org/about-acs/statements/87-surgical-attire

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American College of Surgeons August, 2016

Cleaning the Periop Environment and

EVS Staff Training

Cleaning guide for the OR/Procedure Room

Cleaning in the OR/Procedure Room

Cleaning order in Preop and Postop

Cleaning in the Preop and Postop

NHSN Criteria for SSIs

and Meaningful Data Presentation

Does anyone really understand what Infection Prevention does?

3 Types of SSI’s:

1) Superficial SSI -Infection occurs within 30 days

-Involves only skin or subcutaneous tissue

2) Deep Incisional SSI -Infection occurs within 30 days if no implant left in place

or within 1 year if implant is in place

-Involves deep soft tissue (i.e.. fascial & muscle layers)

3) Organ/Space SSI -Infection occurs within 30 days if no implant left in place

or within 1 year if implant is in place

-Involves any part of the anatomy opened/manipulated with drainage from the organ/space or abscess involving organ/space

NHSN SSI criteria, 2012

• No longer tracking implantable devices for one year

• 30 to 90 days review max

• 14 Procedure types require 90-day monitoring period:

• Breast, Cardiac Surgery excluding CABGs, CABG with both chest & donor incision sites, and CABG with chest incision only, Craniotomy, Spinal fusion, Hip, Knee, Open reduction of fracture, Herniorrhaphy, Pacemaker, Refusion, Peripheral Vascular, & Ventricular shunt

• All other procedures require 30-day monitoring period regardless of presence of an implant

NHSN SSI criteria, 2013

What is the SIR?

Standardized Infection Ratio (“SIR”) • CDC recommends that hospitals use a SIR to measure their

progress as it is a more accurate measurement than a RATE. • It compares the actual number of HAIs reported with the

baseline U.S. experience. • It adjusts for several risk factors that have been found to be

significantly associated with differences in infection incidence.

SIR uses ONE as the benchmark.

SSI from 2007-2012

Healthcare-Associated Infection (HAIs) Housewide

34

910

12

13

17

0

5

10

15

20

25

30

35

40

Nu

mb

er

of

cas

es

Total per Year 10 13 9 12 17 34

2007 2008 2009 2010 2011 2012

CDPH Mandates SSI Reporting for

a total of 29 operative procedures

effective 4/1/2011

2007 SSI Targets:

CABG

Disk/Laminectomy

Spinal fusion

Hip & Knee Prothesis

2008 SSI Targets:

CABG

Disk/Laminectomy

Spinal fusion

Hip & Knee Prothesis

2009 SSI Targets:

CABG

Disk/Laminectomy

Spinal fusion

Hip & Knee Prothesis

2010 SSI Targets:

CABG

Disk/Laminectomy

Spinal fusion

Hip & Knee Prothesis

2011 & 2012 SSI Targets:

All procedures

In 2012, the SIR was 0.31, which is <1.

This signifies fewer infections than expected.

This is good!

Surgical Site Infections (SSI’s) SIR, 2012

2012

Quarters

# actual infections / # expected

infections SIR / 95% Confidence

Interval

1 4 / 20.4 0.196 / 0.053-0.501

2 4 / 20.7 0.193 / 0.053-0.495

3 7 / 20.3 0.344 / 0.138-0.709

4 11 / 21.5 0.512 / 0.256-0.916

Total 26 / 83 0.313 / 0.205-0.459

# actual infections

(actual # procedures

performed)

SIR / 95% Confidence

Interval

HIP – LA COUNTY 2012 57 (9292) 0.6 / 0.46-0.8

HIP – SJHC 2012 4 (970) 0.4 / 0.12-1.14

COLON – LA COUNTY 2012 108 (6102) 0.6 / 0.5-0.7

COLON – SJHC 2012 4 (233) 0.3 / 0.08-0.80

LA COUNTY: 100 HOSPITALS compared to

SAINT JOHN’S SIR for Hips & Colons

2012

Focus: Breast Surgeries, 2015

10 Breast SSIs

390 Breast Surgeries =

my gut says something’s not right

2015 Breast SSI’s

Surgery WC ASA Prep Surgeon

SSI Type Orgs NHSN report

Removal of

infected tissue

expander

(12/16/14)

Dirty II Povidone

Scrub

Surgeon

A

Deep

(Purulent fluid

drainage)

E. Coli,

Proteus

Mirabilis

Yes

(SSI: 1/29/15)

Resection of left

chest wall d/t

recurrent breast

CA (2/23/15)

Clean II Povidone

Iodine

Surgeon

C

Superficial (Positive

culture)

Coag negative

Staph

Yes (SSI:

3/4/15)

Left breast

reconstruction

with tissue

expander

(9/30/15)

Clean II Chloraprep

Surgeon

D

Superficial (fluid

drainage MD

diagnosis as SSI)

Not cultured Yes (SSI:

10/19/15)

B/L mastectomies

(12/14/15)

Clean II Povidone

Scrub

Surgeon E Superficial (Cellulitis

of left breast: MD

diagnosis as SSI)

No growth Yes (SSI:

12/22/15)

Surgery WC ASA Prep Surgeon SSI Type Orgs NHSN report

B/L nipple sparing

mastectomies

(12/17/14)

Clean I Povidone Scrub Surgeon B Superficial

(Removal of Tissue

Expander: MD

diagnosis as SSI)

No growth Yes

(SSI: 1/2/15)

B/L nipple sparing

mastectomies

(4/22/15)

Clean I Povidone Scrub Surgeon B Superficial (Infected

left breast tissue

expander: MD

diagnosis as SSI)

No growth Yes

(SSI: 5/14/15)

B/L nipple sparing

mastectomies

(5/20/15)

Clean II Betadine Surgeon B Superficial (Cellulitis of

right breast: MD

diagnosis as SSI)

No growth Yes

(SSI: 5/25/15)

B/L nipple sparing

mastectomies

(7/8/15)

Clean II Chloraprep Surgeon B Breast

Abscess/Mastitis

(Removal of infected

left breast tissue

expander)

Pseudomonas

aeruginosa

Yes

(SSI: 8/17/15)

B/L nipple sparing

mastectomies

(9/9/15)

Clean III Povidone Scrub Surgeon B Breast

Abscess/Mastitis

(drainage and removal

of silicone implants

and alloderm)

Serratia

marcescens

Yes

(SSI: 9/16/15)

2015 Breast SSI’s continued

Pre-op Skin Prep Surgical Staff EVS Infection Prevention

Preop patient bathing with Hibiclens (CHG)

Primary rec: Alcohol-based prep • Such as, Chloraprep,

Duraprep, etc.

Consistent surgical attire • COVER cloth

caps • Jewelry • dangling Masks

Validate EVS staff for training to clean OR suites

Communicate evidence-based guidelines to Surgery = MDs & staff

Blood Glucose control

Secondary rec: Chlorhexidine based prep • Contraindicated for

mucous membranes & any procedure above neck

Scrub technique • Consistent

throughout Periop

• Ecolab soap & Avagard waterless

• Nail scrubbers

Approved disinfectants & correct contact time

Targeted SSI education: • Surgeons w/

high SSIs • Surgical

services with high SSIs

Hair removal • NOT in OR • Clippers

only

Surgical Safety Checklist • Careful

documentation procedure data (WC, coding)

Cleaning frequency of specific locations in OR suite & use of UV

Communicate SSI data to Surgery = MDs & staff (in addition to committees)

Anderson DJ, Podgorny K, Berrios-Torres, SI, et al. Strategies to Prevent Surgical Site Infections in Acute Care Hospitals: 2014 SHEA Update, Infection Control and Hospital Epidemiology, 2014 June; 35(6), 605-627.

References

• Anderson DJ, Podgorny K, Berrios-Torres, SI, et al. Strategies to Prevent Surgical Site Infections in Acute Care Hospitals: 2014 SHEA Update, Infection Control and Hospital Epidemiology, 2014 June; 35(6), 605-627.

• Association for the Healthcare Environment of the American Hospital Association. Practice Guidance for Healthcare Environmental Cleaning. 2nd ed. Chicago, IL: American Hospital Association; 2012.

• Braswell, M.L., Spruce, L. Implementing AORN Recommended Practices for Surgical Attire, AORN. (January 2012) 122-137. doi: 10.1016/j.aorn.2011.10.017

• Recommended practices for environmental cleaning. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc.; 2014:255-276.

• Sehulster LM, Chinn RYW, Arduino MJ, et al. Guidelines for Environmental Infection Control in Health-Care Facilities. Chicago IL; American Society for Healthcare Engineering/American Hospital Association; 2004. http://www.cdc.gov/hicpac/pdf/guidelines/eic_in_hcf_03.pdf Accessed January 13, 2014.

• American College of Surgeons website review of August, 2016 surgical attire statement: https://www.facs.org/about-acs/statements/87-surgical-attire

Thank you!

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Angela Vassallo, MPH, MS, CIC, FAPIC Director, Infection Prevention/Epidemiology Providence Saint John’s Health Center 2121 Santa Monica Blvd. | Santa Monica, CA 90404 Office: 310.829.8161 | EFax: 310. 264.7271 | angela.vassallo@providence.org 2016 President-Elect, CA APIC http://community.apic.org/thecaliforniaapiccoordinatingcouncil/home