Surgical Site Infection - ANZSVN · Assign admin responsibility to anesthetist or ... v’s...
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Surgical Site Infection
SHERI SANDISON. MN. RN. VASCULAR CPCSALHS
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SSI Risk Factors :
Patient•Comorbidities•Immune status•Colonisation
Pathogen•Virulence•Resistance
Procedure•Duration•Preparation•Type / technique•Equipment sterilization
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Vascular patients = high risk:
Multiple comorbidities Infected tissue Malnourished Immuno‐suppressed Poor perfusion History resistance (MRSA / VRE) Long procedures / multiple procedures Short prep time (urgent / semi‐urgent) In substandard angio suites.
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Reduce risk of SSI:
Pre‐op Peri ‐op
Post‐op
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Prevention Strategies
Core Strategies
High level of evidence
Demonstrated feasibility
Supplemental strategies
Some evidence
Variable levels of feasibility
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Pre‐op Strategies
Remove infections where possibleIdentify & treat before elective surgeryPostpone until infection resolvedRemove infected tissue (drain diabetic foot / guillotine amputation)
DOSA admission (decreased cross transfer –nosocomial infections)
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Pre‐op Strategies
Do not remove hair unless interferes with surgeryProtocol for preop hair removalNo Razors – use ClippersClip as close as possible to incision time Protocols & educationEducate patients not to self shave preop.
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Pre‐op Strategies
Antibiotic prophylaxis In accordance to guidelines / standards for procedure,
common local pathogen, published recommendations.ProtocolTimed to allow tissue penetrationEnsure processes to ensure preop administration for
vancomycin Discontinue antibiotics within 24hrs. Adjust dose for obese patient
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Antibiotic Admin. StrategiesAntibiotic prophylaxis Pre‐printed standard orders OR drug stocks to include ONLY standard guideline drugs
Assign admin responsibility to anesthetist or holding room nurse.
Team time out Visible reminders / check lists, stickers, stop signs Involve ID, Pharmacy in protocol; development / implementation guidelines.
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Pre‐op Strategies
Skin Prep:Chlorhex & alcohol (3 hours life) v’s betadine (20 min life)Processes to prevent fire (Alcohol + Diathermy)Tinted to ensure visible coverage
Nasal screening & de‐colonise (mupiricin) Screen preop glucose – maintain tight glucose control Preop chlorhex sponge shower (night before & morning
of) Patient education about SSI, strategies & their role Smoking cessation
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Intra‐op Strategies
OR environment OR traffic reduce /Close theatre doors (issue with angio suites if not true
theatre standard) Theatre cleaning Laminar flow Hand wash with antiseptic & approved technique Sterile gowns Sterile instruments Hats / masks Jewelry / artificial nail & polish removed Sterile gloves (double glove) No infected staff Aspesis Only iodophor impregnated drapes Diathermy does not reduce SSI risk
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Intra‐op Strategies
Maintain normothermiaWarmed blankets (pre/ intra /post)Warmed fluidsWarming blankets on OR tableHats & booties peri op
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Intra‐op Strategies
Maintain haemostasisAdequate perfusionMaintain glucose level (< 11mmol/l) Maintain o2 level (>95%)
Repeat antibiotics for lengthy procedure (3 –4hours – specific guidelines)
Handle tissue gently – haematoma = infectionApply sterile dressingDon’t use irrigation / intra‐cavity lavage to
reduce risk
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Post‐op Strategies
Surgical dressing in place for 48 hoursChange dressing using aseptic techniqueSafe to shower at 48 ours Occlusive dressing to prevent strike throughControl post op glucose levels (<11mmol/l)Discontinue antibiotics within 24hrs. SSI surveillance & audit Reduce LOS
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Research opportunities
Nasal decontamination in high risk vascular patients
Supplemental O2 in recovery Preop glucose screening & post op control Closure methods Wound dressing types (Occlusive, antimicrobial, TNP)
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References
Casey AL, Elliott TSJ. Progress in the prevention of surgical site infection. Curr Opin Infect Dis 2009;22:370‐375
Chong T, Sawyer R. Update on the epidemiology and prevention of surgical site infections. Curr Infect Dis Rep 2002;4:484‐490)
Department of Health and Human Services. Action Plan to Prevent Healthcare‐Associated Infections. http://www.hhs.gov/ophs/initiatives/hai/infection.html Accessed 17 February 2010
Fry DE. A systems approach to the prevention of surgical infections. Surg Clin N Am 2009;89:521‐537.
Haynes AB, Weiser TG, Berry WR, et al,. A surgical safety checklist to reduce morbidity and mortality in a global population. N Eng J Med 2009;360(5):491‐499.
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References
Horan TC, Andrus M, Dudeck MA. CDC/NHSN surveillance definition of health care‐associated infection and criteria for specific types of infections in the acute care setting. Am J Infect Cotrol 2008;36:309‐32
Kirby JP, Mazuski JE. Prevention of surgical site infection. Surg Clin N Am 2009;89:365‐389.
Mangram AJ, Horan TC, Pearson ML, et al. Guideline for the prevention of surgical site infection, 1999. Hospital Infection Control Practices Advisory Committee. Infect Control Hosp Epidemiol 1999; 20:250‐278.
Nichols RL. Preventing surgical site infections. Clin Med Res 2004;2(2):115‐118.
World Alliance for Patient Safety. WHO guidelines for safe surgery. Geneva: World Health Organization, 2008
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References
http://www.nice.org.uk/nicemedia/pdf/CG74NICEGuideline.pdf
http://www.cdc.gov/HAI
http://www.health.vic.gov.au/sssl/downloads/prev_surgical.pdf
http://www.hps.scot.nhs.uk/haiic/ic/publicationsdetail.aspx?id=50997
http://www.documents.hps.scot.nhs.uk/hai/infection‐control/evidence‐for‐care‐bundles/key‐recommendations/ssi.pdf
http://www.nhmrc.gov.au/book/australian‐guidelines‐prevention‐and‐control‐infection‐healthcare‐2010/b4‐3‐2‐minimising‐risk‐s