"SSI Prevention:  Preparing for the future by going back to the basics"

Presented by:

Kathleen Kohut, RN, MS, CIC, CNORSystem Director of Infection PreventionCone Health, Greensboro, NC

Speaker Disclosures

3M AMN Healthcare The Compass Group BE Smith Consulting Johns Hopkins Hospital NCH Healthcare System APIC

Learning Objectives

1. Discuss the five basics of SSI prevention

2. Describe the use of glycemic control, nasal decolonization, and normothermia initiatives for the reduction of SSIs.

3. Name the 2 most common mechanisms for wound contamination

4. Name 3 SCIP Measures

5. Discuss two opportunities for practice improvement

PREPARING FOR THE FUTURE

Current National SSI Initiatives include:

The Joint Commission National Patient Safety Goal NPSG.07.05.01 included in 2009

CMS Public reporting requirements for SSIs 2012 - Colon Resections and Abd Hysterectomies▪ Nationally

SCIP Quality Measures

1. Antibiotic Prophylaxis ( Inf- 1,2,3) Drug, Timing, Dosing, Discontinuation

2. Hair Removal (Inf- 6)

3. Glycemic Control (Inf – 4)

4. Foley Catheter removal POD1 or POD2 (Inf- 9)

5. “Normothermia” (Inf 10) Expanded in June 2011 All surgical patients

http://www.jointcommission.org/specifications_manual_for_national_hospital_inpatient_quality_measures.aspx

http://www.jointcommission.org/assets/1/6/Surgical%20Care%20Improvement%20Project.pdf

Barriers to Progress in SSI Prevention

SSI is an unfortunate possibility (it says so right on the consent form)

Challenge-change the culture of tolerance to one of intolerance to SSI

The Business Case- maximization of OR volume to increase revenueChallenge- improve efficiencies without compromising infection prevention

TraditionChallenge- re-examine practices from a fresh perspective to find new

opportunities

Lack of researchChallenge- conduct research and publish to create a solid body of evidence

Going Back to the Basics

Five Focus Areas:

1. Patient Preparation2. Aseptic Technique3. ABX Prophylaxis4. Hair Removal5. Skin Antisepsis

1. Optimal Patient Preparation Includes:

Losing weight, quitting smoking

Glucose Management

Nasal Decolonization

Normothermia – pre-warming

Diabetes

The stress response induced by surgical procedures increases blood glucose levels

Non-diabetics may also experience hyperglycemia during this critical perioperative period

CDC(2011). http://www.cdc.gov/diabetes/pubs/factsheet11.htm; accessed on May 10, 2013.

Glycemic Control

>25 million Americans diagnosed with diabetes

> 7 million are undiagnosed 79 million considered pre-diabetic 30-35% of cardiac patients are

diabetics

http://www.cdc.gov/diabetes/pubs/factsheet11.htm

Glycemic Control

SCIP INF 4: Cardiac surgery patients with controlled 6 a.m. postoperative serum glucose.

All Patients should be managed with a target of <200

The first 24 hours is critical

The OR cannot be a black hole

S. aureus Nasal Carriage

Between 25-30% of all patients are colonized at any given time and another 60% carry it intermittently.

Carriers are at higher risk S. aureus causes 25-35% of all HAIs 20% of all surgical pts acquire some type of

HAI during their postoperative course

Perl, TM, et al. Intranasal Mupirocin to Prevent Postoperative Staphylococcus Aureus Infections. N Engl J Med 2002; 346(24): 1871-7.

Nasal Decolonization

85% of S. aureus infections were endogenous in SSI study populations Van Rijen, et al. Intranasal Mupirocin for reduction of S. aureus in surgical patients with nasal carriage. J Anti Chemotherapy 2008; 61:254-261.

MRSA SSI rates decreased from .23% to .09% (5,094 pts) with MRSA eradication program

Pofahl, WE, et al. Active Surveillance Screening of MRSA and Eradication of the Carrier State Decreases Surgical-Site Infections Caused by MRSA. J Am Coll Surg 2009;208:981-988.

Normothermia

SCIP Measure Inf-10

Includes all SCIP surgical patients (June 2011)

▪ Total Knee, Hip, Vascular, Cardiac, ABD Hyst, Colon Resect

Requires one temperature > 96.8º F(36º C) 30 min. before or 15 min after anesthesia end time.

Start with pre-warming

2. Aseptic Technique

Principles were developed to reduce the risk of wound contamination.

Defining the Risk of SSI

Risk of SSI = Dose of Bacterial Contamination X VirulenceResistance of Host (patient)

Berry & Kohn’s, Operating Room Technique, 11th ed., p. 254

Causes of Wound Contamination

1. Exogenous sources Cleanliness of environment, lack of proper

airflow, shedding by the Surgical Team

2. Endogenous sources Patient’s own skin/hair Infection at a remote site

The Number One Source

People = Shedding4000-10,000 particles per minute

(Berry & Kohn’s, Operating Room Technique, 11th ed., p. 252)

Carried by wind currents to the sterile field which results in wound contamination.

1. Patient2. Surgical Team 3. Ancillary Personnel4. Sales Reps5. Students6. Passersby

Traffic Control

Requires the control of the amount of traffic and the traffic patterns themselves Essential personnel only

One foot (min) perimeter around sterile field

Sterile fields should be a destination, not a thoroughfare

Limit students and observers▪ The right of the student to learn vs. the right of the patient to receive safe

patient care

Utilize alternative methods of communication

Sherertz, et al. “Cloud” HCWs. Emerging Infect Dis. 2001;7(2): 241-44.

Edmiston, et al. Airborne Particulates in the OR Environment. AORN 1999; 69(6): 1169-1183.

Kohut SSI Equation

People + Wind + (-) Aseptic Technique > ABX + Skin Prep =

Wound Contamination = SSI

Containment is the key

Patient Opportunities Pre-op showering program

-At least 2 showers with CHG Hat and clean gown/linen for patient transport Hair removal only when necessary

Clippers, not in the OR

Association of periOperative Registered Nurses (AORN). Recommended Practices for Perioperative Patient Skin Antisepsis. Perioperative Standards and Recommended Practices 2013 ed., pp75-89.

Chlebicki MP, et al. Preoperative chlorhexidine shower or bath for prevention of surgical site infection: A meta-analysis. Am J Infect Control 2013;41:167-73.Newsmanager.commpartners.com/shea/issues/2013-04-02/1.html. Accessed 4/3/13.

Containment is the key

Surgical Team

Hand Hygiene Nocardia farcinica (Wenger, et al. J Infect Dis. Nov 1998)

Proper aseptic technique

Properly worn hats, masks, clean OR scrubs, jackets, minimal jewelry (AORN scrub attire)

Ban Skull Caps

If it takes 17 years to adopt new technology, our time is up!

Dineen, P, Drusin, L. Epidemics of Postoperative Wound Infections Associated with Hair Carriers. Lancet 1973; (Nov) 1157-59.

Institute of Medicine (IOM). (2001). Crossing the quality chasm. Crossing the quality chasm: A newhealth system for the 21st century. Washington: National Academy Press.

Other Industries

THE JACKSON LABORATORYBIOTECHNOLOGY COMPANY

COSTCO

Environment

Room Requirements• Ventilation System ▪ (min 15- recommended- 20-25/hr, 3 fresh)▪ Positive pressure

• Temperature (68-73° F)• Humidity (20-60%)

Room Cleaning• Between cases• Terminal cleaning• Types of construction materials• Clutter

AORN, Recommended Practices for Perioperative Nursing: Patient & Worker Safety. (2011 ed., p 219-221)

3. Antibiotic Prophylaxis

SCIP Measures - INF 1,2,3 and NPSG.07.05.01 (#7) Goal >95%▪ Challenge the organization to 100%

Proper dosage for obese population (BMI>30)(Surg 1989;106:750)

Redosing q 3 hours (Ann Surg 2009; 250:10)

• RCA or Med Error if missed

Bratzler, DW, et al. Clinical practice guidelines for antimicrobial prophylaxis in surgery. Am J Health-Syst. Pharm. 2013;70:195-283.

4. Hair Removal

1. SCIP measure (Inf-10)

2. NPSG.07.05.01 (#8)Goal

Minimize as much as possibleClippers only

3. Not addressed: Location of hair removal

5. Skin AntisepsisThe attributes of an appropriate surgical skin antiseptic

require: The ability to significantly reduce microorganisms (2 log-dry sites, 3 log-wet sites) Provide broad spectrum activity Be fast acting Have a persistent effect

All products with FDA approval meet this criteria

Association of periOperative Registered Nurses (AORN). Recommended Practices for Perioperative Patient Skin Antisepsis. Perioperative Standards and Recommended Practices 2013 ed., pp75-89.

Other Skin Antisepsis Considerations

1. Procedure (location and type of incision site) May challenge the prep area with the presence of blood,

saline, friction from retractors, etc.2. Patient Safety

Consider not using alcohol based preps for head and neck surgeries due to the highest risk of fire.

There are no specific recommendations…

CDC SSI guideline states to “use an appropriate antiseptic”

SHEA Compendium - “Optimal preparation and disinfection of the operative site”

AORN compares products but does not provide specific product recommendations

NQF 2011 recommendation: “use solutions that contain isopropyl alcohol as skin antiseptic preparation until other alternatives have been proven as safe and effective, and allow appropriate drying time per product guidelines.”

National Quality Forum: http://www.qualityforum.org/News_And_Resources/Press_Releases/2011/NQF_Maintains_Endorsement_of_Safe_Practice_to_Prevent_Surgical_Site_Infection.aspx

Surgical Skin Antisepsis Research

Limited research is available that compares commonly used skin antiseptic agents with SSI outcomes

The majority of the literature compares microbial counts

Much more work must be done to create a body of evidence to guide practice

Current Research

Saltzman, MD, et al. Efficacy of Surgical Preparation Solutions in Shoulder Surgery. J Bone Joint Surg AM 2009;91:1949053

Microbial culture study of 150 patients comparing 3 methods (Iodophor Scrub/Paint vs. ChloraPrep® vs. Duraprep™)

Swenson, et al. Preoperative skin preparation on postoperative wound infection: a prospective study of three skin preparation protocols. Infect Control Hosp Epidemiol 2009; 30:964-971▪ SSI Outcome study of 3209 pts comparing 3 methods (Iodophor Scrub/ETOH/Paint vs.

ChloraPrep® vs. DuraPrep™

Darouiche, RO, et al. Chlorhexidine-Alcohol versus Povidone-Iodine for Surgical-Site Antisepsis. N Engl J Med 2010; 362(1):18-26.

Microbial culture study of 849 patients comparing 2 methods (Iodophor Scrub/Paint vs. Chlorhexidine-alcohol)

Savage, JW et al. Efficacy of Surgical Preparation Solutions in Lumbar Spine Surgery. J Bone Joint Surg Am. 2012;94:490-4

Efficacy study comparing ChloraPrep® to DuraPrep™ preop, post prep, and post-op

Clear as Mud……..

Alcohol

Isopropyl Alcohol

Mechanism of actions: Denatures (kills) proteins

Bactericidal Fungicidal Virucidal Does not kill spores

Has no persistent effect

Association of periOperative Registered Nurses (AORN). Recommended Practices for Perioperative Patient Skin Antisepsis. Perioperative Standards and Recommended Practices 2013 ed., pp75-89.

Product Application Methodology

Follow manufacturer’s directions Read the labels!

Utilize proper aseptic technique during application & gloves to contain shedding

Facilitating Process Improvements

Create relationships between IP, OR, SPD, Pre-op, Surgeons (and their offices):

Learn how they do their work Learn how you can help each other Choose process measures together Its about partnering not policing

Process Improvements

Provide process data on an ongoing basis Maintains focus▪ IUS rates▪ Compliance with surgical attire

Review outcome data regularly SSI Rates

Summary

SSIs are preventable and there is much work to be done

The tools for success include SCIP measures, NPSG.07.05.01, process and outcome data and the operating room basics to:

1. Educate2. Measure3. Communicate

Questions?

kathleen.kohut@conehealth.com