Surgical Site Infections: Preparing Our Patients For Surgery.
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Transcript of Surgical Site Infections: Preparing Our Patients For Surgery.
Surgical Site Infections:Preparing Our Patients For Surgery
Our Last Call Together• Three problems that sit at the core of surgical
site infections– Doing reliably what we know needs to be done– Teamwork and communication– Always being vigilant about keeping the patient
safe• The South Carolina Surgical Safety Checklist
as a drug
Preventing SSI’sPre-Incision Incision/Surgery Post Op
Patient
• Basics of Skin Prep
• Showers• Skin Wipes
• Hair Removal• Weight Based
Dosing• MRSA Screening • Glucose Control
• Glucose Control• Hyperoxia
• Wound care• Dressings
Operation
• Antibiotic• Bowel Prep
• Re-dosing• Operating Time• Use of Tourniquet• Surgical Technique• Wound protectors
Environment
• Basics of Sterility• Instrument Sterility• Hand Hygiene• Temperature
Control• Teamwork• Culture
• Basics of Sterility• Instrument Sterility• Hand Hygiene• OR Traffic• Temperature Control• Teamwork• Culture
• Discontinue antibiotics
• Teamwork• Culture
Todays Topics• Chlorhexidine Wipes• Preoperative Bacterial Screening• Keeping Your Patient Warm• Alcohol-Based Skin Preps
Chlorhexidine Wipes:Common Sense Science
• Bacteria on the skin is bad. Wiping the skin with chlorehexidine could be good
• Started in the ICU when patients who bathed with chlorexidine impregnated cloths on a daily basis developed fewer bloodstream infections
• Patients are less likely to develop a SSI if they use wipes the night and morning before their procedure1
• 50% overall reduction in SSI in orthopaedic surgery1
• Studies show that even if patients are not fully compliant wipes still can have an impact2
1. Eiselt. Presurgical Skin Preparation With a Novel 2% Chlorhexidine Gluconate Cloth Reduces Rates of Surgical Site Infection in Orthopaedic Surgical Patients. Orthopaedic Nursing. 2009; 28: 141-145 .2. Zywiel et al. Advance pre-operative chlorhexidine reduces the incidence of surgical infections in knee arthroplasty. International Orthopaedics. 2011; 35; 1001-1006.
Useful Resources
The Institute for Healthcare
Improvement has examples of patient
materials for preparing skin before surgery
http://www.ihi.org/knowledge/Pages/Tools/PreparingYourSkinBeforeSurgeryPatientInstructionsSSI.aspx
Preoperative Bacterial Screening:Common Sense Science
• Patients who carry Staphylococcus aureus (SA) are more likely to develop a surgical site infection
• Patients should be screened prior to surgery
• Schedule the screening so there is enough time to kill the bacteria
How-to Guide: Prevent Surgical Site Infection for Hip and Knee Arthroplasty. Cambridge, MA: Institute for Healthcare Improvement; 2012. (Available at www.ihi.org)
S. Aureus Nasal Carriage
Kluytmans. Clin Microbiol Rev 1997; 10:505
Persistent carriersAlways carry one strain of S.
aureus20%
Intermittent carriersCarry different strains of S.
aureus intermittently60%
Noncarriers 20%
S. Aureus Nasal CarriageUsual PrevalencePopulation Percentage
General population 20%
Health care workers 27%
Patients on admission 36%
Patients on insulin 56%
Hemodialysis patients 52%
Chronic renal failure 21%
I.V. drug users 55%
Kluytmans. Clin Microbiol Rev 1997; 10:505
Useful Resources
The Institute for Healthcare
Improvement has sample tools for
educating patients
http://www.ihi.org/knowledge/Pages/Tools.aspx
Keeping Your Patient Warm: Common Sense Science
• Human beings are warm-blooded• The body fights infection better when it is
warm• The operating room is a cold place• Keeping patients warm can be a challenge• The best thing to do is to never let your
patient get cold
Redistribution Hypothermia
Core37°C
Vasoconstricted
Periphery31-35°C
Anesthesia
Periphery33-35°C
Core36°C
VasodilatedDellinger. Preventing SSI – Some Things Old and Some Things New. HRET Hospital Engagement Network Meeting. May 2012 .
Perioperative Warming, Intraoperative Temperature and
Complications
Wong. Br J Surgery 2007; 94: 423-6
PeriopN=47
StandardN=56
P Value
Blood loss 200 ml 400 ml 0.011
Any complication 32% 54% 0.027
SSI 13% 33% 0.09
Temperature and SSI Following Colectomy
Kurz. NEJM 1996;334:1209
Normo (104)
Hypo(96)
P Value
SSI 6 18 .009
Keep your patient warm before they go to surgery
• It is like “money in the bank”• Use warming blankets before they go into
the OR• Think about putting a hat on your patient
Dellinger. Preventing SSI – Some Things Old and Some Things New. HRET Hospital Engagement Network Meeting. May 2012How-to Guide: Prevent Surgical Site Infections. Cambridge, MA: Institute for Healthcare Improvement; 2012. .
Keeping Your Patient Warm in the O.R.
• Pre-warming and active warming in the OR is much more important than the OR room temperature
• Put warming blankets under and over your patient on the operating table (if possible)
• Use warmed fluids for IVs• Use warm irrigation on the field (if possible)
Dellinger. Preventing SSI – Some Things Old and Some Things New. HRET Hospital Engagement Network Meeting. May 2012How-to Guide: Prevent Surgical Site Infections. Cambridge, MA: Institute for Healthcare Improvement; 2012. .
Alcohol-Based Skin Preps: Common Sense Science
• The combination of alcohol together with another agent is probably better because there are two things killing the bacteria
• An antibacterial prep that lasts on the skin is better than one that doesn’t1
• If you don’t let the prep dry or wipe it off it can’t work because it is not on the skin anymore
1. Darouiche RO, Wall MJ Jr, Itani KM, et al. Chlorhexidine-alcohol versus povidone-iodine for surgical-site antisepsis. N Engl J Med. 2010;362(1):18-26.2. Swenson BR, Hedrick TL, Metzger R, Bonatti H, Pruett TL, Sawyer RG. Effects of preoperative skin preparation on postoperative wound infectionrates: A prospective study of 3 skin preparation protocols. Infect Control Hosp Epidemiol.
No skin prep will be effective if you don’t use it the way that
you are supposed to• Let the prep completely dry prior to draping• Avoid pooling of the skin prep
How-to Guide: Prevent Surgical Site Infections. Cambridge, MA: Institute for Healthcare Improvement; 2012
Take Home MessagesPre-Incision Incision/Surgery Post Op
Patient
• Basics of Skin Prep
• Showers• Skin Wipes
• Hair Removal• Weight Based
Dosing• MRSA Screening • Glucose Control
• Glucose Control• Hyperoxia
• Wound care• Dressings
Operation
• Antibiotic• Bowel Prep
• Re-dosing• Operating Time• Use of Tourniquet• Surgical Technique• Wound protectors
Environment
• Basics of Sterility• Instrument Sterility• Hand Hygiene• Temperature
Control• Teamwork• Culture
• Basics of Sterility• Instrument Sterility• Hand Hygiene• OR Traffic• Temperature Control• Teamwork• Culture
• Discontinue antibiotics
• Teamwork• Culture
??Questions
Upcoming Calls
Thursday, June 13th 2:00-2:45Preventing VTE’s in Surgical Patients
Thursday, June 27th 2:00-2:45Other Ways of Preventing Venous
Thromboembolism
Office Hours:Wednesday 2:00-3:00