the Slide Set
Transcript of the Slide Set
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Slide 1
Tuesday, April 12
1:00 pm EasternDial In: 888.863.0985
Conference ID: 59378418
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Slide 2Slide 2
Speakers
David Soper, MD, FACOG
Professor & Director, Obstetric & Gynecologic Specialists,
Medical University of South Carolina
Paloma Toledo, MD, MPH
Assistant Professor, Anesthesiology, Northwestern University
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Slide 3
Disclosures
David Soper, MD, FACOG has no real or perceived conflicts of interest to disclose.
Paloma Toledo, MD, MPH has no real or perceived conflicts of interest to disclose.
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Slide 4
Objectives
Discuss the important role that the multidisciplinary care team plays in helping prevent surgical site infections.
Review the composition and characteristics of successful multidisciplinary care teams.
Identify valuable strategies that can be utilized by care teams, including time outs, huddles, and debriefs.
Provide tips on how your institution can successfully employ a team-based approach to aid in reducing surgical site infections.
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Slide 5
Prevention of InfectionElements of a Checklist
• Control diabetes
• Preop showers
• Clippers – no razors
• S. aureus awareness*
• Normothermia*
• Antibiotic prophylaxis*
• Vaginal preparation
• Skin preparation
• Neg pressure wound Rx
• Postop incision care
*Anesthesiology
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Slide 6
ReadinessPreoperative Standards
• Assigning responsibilities
• Preoperative care and education (nursing)
– Chlorhexidine showers/postop wound care
• Evidence based standards
– Normothermia (Anesthesiology)
– Antibiotic prophylaxis (Surgeon + Anesthesiology)
– Skin preparation (Surgeon)
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Slide 7
Preoperative Showers
• Chlorhexidine showers
• Cruse 1980 = 10,000 patients prospective
• Recent meta-analysis less clear (Cochrane)
• OR 0.2 (0.06-0.7)
– 80% reduction*
* Savage, et al. Surgical site infections and cellulitis after abdominal hysterectomy. AJOG 2013:209:108.e1-10
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Slide 8
RecognitionAmeliorate Risk Factors
• Anticipate and plan
• Risk Factors
– Blood glucose level
– BMI
– Bacterial vaginosis screening
– MRSA awareness
– Nutritional status
– Smoking
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Slide 9
Diabetes Control
• Real issue is postoperative control
• Good preoperative control makes postoperative easier
• Risk increases for postoperative glucose
– Mean 150-250 = 22% increase
– Mean >250 = 44% increase
• Preoperative guideline = A1c < 8%
– Mean glucose 200 mg/dl
King, et al. Glycemic control and infections in patients with diabetes undergoing non-cardiac surgery. Ann Surg 2011;253:158-65
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Slide 10
PPE: OR = 5.8 [3.0-10.9] Cuff cellulitis: RR=3.2 [1.5-6.7]
Watts H, Krohne MS, Hillier SL, Eschenbach DA. Bacterial vaginosis as a risk factor for post cesarean endometritis. Obstet Gynecol 1990;75:52-8
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Slide 11
Hysterectomy SSIBacterial Vaginosis
• Increases risk of SSI
– RR = 3.2 (1.5 to 6.7)
• McElligott cost comparison study
– Screen for BV vs treat all vs neither
– Optimal strategy = treat all patients for BV
• If screen positive – 7 days of therapy
McElligott, et al. Preoperative screening strategies for bacterial vaginosis prior to elective hysterectomy: a cost comparison study. AJOG 2011;205:500.e1-7
Larsson, et al. Clue cells in predicting infections after abdominal hysterectomy. Obstet Gynecol 1991;77:450-2
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Slide 12
MRSA
• Universal, rapid MRSA admission screening did NOT reduce nosocomial infection
• 266 identified as MRSA positive preop
– 115 given preop MRSA prophylaxis
• 0/115 given preop ab prophylaxis active against MRSA developed MRSA infection
Harbarth, et. al. Universal screening for methicillin-resistant staphylococcus areus at hospital admission and nosocomial infection in
surgical patients. JAMA 2008;299(10):1149-1157
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Slide 13
MRSAMUSC Approach
• History of MRSA colonization or infection
• Current culture evidence of MRSA colonization
• Undergoing surgical procedure that warrants antibiotic prophylaxis
• Add vancomycin to antibiotic prophylaxis regimen
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Slide 14
Surgical Care Improvement Project (SCIP) Measures
• SCIP-Inf-1a: Prophylactic antibiotics within 1 hour of surgical incision – overall rate
• SCIP-Inf-2a: Proportion of patients who received prophylactic antibiotics consistent with current guidelines – overall rate
• SCIP-Inf-3a: Prophylactic antibiotics were discontinued within 24 hours of surgery end time –overall rate
• SCIP-Inf-6: Proportion of patients with appropriate hair removal
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Slide 15
Team-Approach to Antibiotic Administration
• Pharmacy-generated antibiotic order sets
• Pharmacy to prepare antibiotics
• Nursing or anesthesia staff verifying antibiotic, patient allergies, correct dose
• Administration of antibiotics within one hour of incision
• Use of the team time out to verify antibiotic administration prior to incision
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Slide 16
Antibiotic Selection
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Slide 17
Standardized Order Sets
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Slide 18
Standardized Order Sets
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Slide 19
Obesity and Weight Based DosingAntimicrobial Prophylaxis
• Obesity – >220# (100 kg) or BMI > 35
– Increase dose of cefazolin
Forse RA, Karam B, MacLean LD, Christou NV. Antibiotic prophylaxis for surgery in morbidly obese patients. Surgery 1989;106:750-7
Time Serum level Adipose tissue (minutes) (g/ml) level (g/gm)
Group Incision Closure Incision Closure Incision Closure
A (control) 13.5 + 6.3 98.1 + 25.2 110.5 + 18.9 44.5 + 7.4 6.0 + 1.3 4.1 + 0.8
C (1 gm IV) 12.7 + 7.8 123.9 + 20.8 65.2 + 15.0* 23.5 + 5.1* 4.0 + 2.3 † 2.4 + 1.0 †
D (2 gm IV) 15.7 + 8.2 116.5 + 22.8 127.8 + 16.3 46.2 + 9.9 7.3 + 3.1 4.1 + 1.1
*Significantly (p < 0.001) different from control group A by ANOVAR†Significantly (p <0.01) different from control group A by ANOVAR
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Slide 20
Antibiotic Administration
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Slide 21
Timing of Antibiotic Administration
Classen DC, et al. The timing of prophylactic administration of antibiotics and the risk of surgical-wound infection. New England Journal of Medicine 1992;326:281-6
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Slide 22
Huddles/Team Time Out
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Slide 23
Sign In/Time Outs
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Slide 24
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Slide 25
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Slide 26
Impact of Checklist Use
Before ChecklistN=3733
After checklistN=3955
P
Rate of Death 1.5% 0.8% 0.003
Inpatient Complications
11% 7% P<0.001
Haynes, A, et al. A Surgical Safety Checklist to Reduce Morbidity and Mortality in a Global Population. New England Journal of Medicine. 2009; 360: 491-9.
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Slide 27
Time Out
• Elements include:
– Patient identification
– Procedure(s)
– Risks including anticipated EBL
– Use of antibiotic prophylaxis
– Anticipated difficulties
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Slide 28
Changes in Intraoperative Conditions
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Slide 29
Northwestern Postpartum Hemorrhage Protocol
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Slide 30
Northwestern Postpartum Hemorrhage Protocol
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Slide 31
Re-dosing of antibiotics
• Add intraoperative doses for long cases
– 1 - 1.5 times the half-life of the antibiotic
– Cefazolin half life = 1.8 hours
• Administer second dose ~ 4 hours
• Second dose for increased blood loss
– > 1500 cc
Swoboda SM, et al. Does intraoperative blood loss affect antibiotic serum and tissue concentrations? Arch Surg 1996;131:1165-72
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Slide 32
Maintenance of Intraoperative Normothermia
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Slide 33
Intraoperative Normothermia
• Randomized controlled trial, n=200
• Routine intraoperative care (hypothermia) vs. active warming
Kurz, Andrea et al. Perioperative normothermia to reduce the incidence of surgical-wound infection and shorten hospitalization. New England Journal of Medicine 1996; 334: 1209-15
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Slide 34
Intraoperative Normothermia
NormothermiaN=104
HypothermiaN=96
P
Vasoconstriction 22% 78% <0.001
Surgical site infection
6% 19% 0.009
Kurz, Andrea et al. Perioperative normothermia to reduce the incidence of surgical-wound infection and shorten hospitalization. The New England Journal of Medicine.
1996; 334: 1209-15
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Slide 35
Recommendations for Maintaining Normothermia
• Room temperature 68-72°F
• Use of active warming devices, if indicated
– Use of warming blankets
– Use of fluid warmers
• Team communication if issues with intraoperative temperature
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Slide 36
Prevention of SSI
• Clippers = less SSI vs razor
– Cochrane review
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Slide 37
Chorhexidine-alcohol Skin Preparation at Time of Surgery
Darouiche RO et al. Chlorhexidine-alcohol versus povidone-iodine for surgical-site antisepsis. The New England Journal of Medicine 2010;362:18-26
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Slide 38
Hysterectomy Wound InfectionDepth of Subcutaneous Tissue
Soper, DE, et al. Wound infection after abdominal hysterectomy: Effect of the depth of subcutaneous tissue. AJOG 1995;173:465-71
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Slide 39
Closure of Subcutaneous Fat
• Meta-analysis
• Cesarean delivery – n = 875
• Wound disruption – RR = 0.56[0.36-0.86]
– Decrease in wound seromas
– For thickness > 3
Chelmow, et al. Suture Closure of Subcutaneous Fat and Wound Disruption After Cesarean Delivery: A Meta-Analysis. Obstet Gynecol 2004;103:974-980
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Slide 40
Subcuticular Skin Closure
• No staples!
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Slide 41
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Slide 42
Negative Pressure Wound Therapy
• Cesarean at risk for infection
– Including BMI > 30
• Note association of seroma with SSI
– Savage 2013 AJOG – OR 6.7 (3.5-12.8)
• NPWT until discharge (average 3 days)
• NPWT lower rate of wound infection
– 2.7% vs 11.5%
Swift, et al. Effect of single-use negative pressure wound therapy on post-cesarean infections and wound complications for high-risk patients. J Reprod Med. 2013;60:211-8
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Slide 43
Prevention of InfectionHysterectomy Checklist
• Control diabetes
• Preop showers
• Clippers – no razors
• S. aureus awareness
• Normothermia
• Antibiotic prophylaxis
• Vaginal preparation
• Skin preparation
• Subcutaneous closure
• Subcuticular
• Neg pressure wound Rx?
• Postop incision care?
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Slide 44
MUSC Opportunities
• Attention to postoperative glucose control
• Preop showers with chlorhexidine
• MRSA awareness
– Review culture record
– History consider positive
• Increase dose of cefazolin
– 2 grams for all with 3 grams for > 120 kg
• Negative pressure wound therapy? - investigation
• Postop incisional care?
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Slide 45
It Takes a Village
• 120 lives had to be touched to hardwire our SSI prevention program
• Standardization and SYSTEMS development = ABOG MOC credit
– Can’t be the Lone Ranger
• Real time review of each SSI
– Make sure definitions are met
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Slide 46
Data Collection, Measurement, and Reporting
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Slide 47
Data Collection
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Slide 48
Process Measures
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Slide 49
Provider and Surgical Process Measures
Potential Measures
Provider • Adherence with hand washing• Adherence with use of proper surgical attire
Surgical • Proper preoperative skin antisepsis• Proper preoperative hair removal• Proper operating room temperature• Appropriate re-dosing of antibiotics (e.g. due to prolonged
duration of surgery, excessive blood loss)
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Slide 50
Outcome Measures
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Slide 51
Sources to identify infection data
• ICD-9/ICD-10 codes
• Readmission for treatment of surgical site infections
• Surveys
• Microbiology reports
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Slide 52
Risk Adjustment
Risk Factors
Patient-level risk factors • Obesity• Diabetes mellitus• Smoking status• Steroid use• Nutritional status• American Society of Anesthesiologists
Physical Status (ASA PS)
Surgical-level risk factors
• Type of surgery• Duration of surgery• Insertion of foreign material
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Slide 53
National Healthcare Safety Network (NHSN) index
• Three variables contribute one point each:
– American Society of Anesthesiologists Physical status score >3
– Contaminated or dirty wound classification
– Procedure duration > 175th percentile
• Scores range from zero to three
– Zero represents the lowest risk
– Three represents the greatest risk
Culver DH, et al. Surgical wound infection rates by wound class, operative procedure, and patient risk index. National Nosocomial Infections Surveillance System. Am J Med
1991; 91: 152S-157S
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Slide 54
Standardized Infection Ratio (SIR)
• Accounts for patient- and procedure-related risk factors within each type of surgery (e.g. patient age, wound class, duration of surgery)
• Compares the number of infections that were observed at the hospital-, state-, or national-level, with the number of predicted infections. – Ratio <1: Fewer infections were observed than
expected
– Ratio>1: More infections were observed that were expected
Centers for Disease Control and Prevention (CDC). Healthcare-associated Infections http://www.cdc.gov/hai/surveillance/progress-report/faq.html. Accessed on: 3/24/16
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Slide 55
Reporting
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Slide 56
Dashboards or Scorecards
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Slide 57
National Reporting
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Slide 58
Multidisciplinary review
• Physicians
– Surgeons
– Anesthesiologists
• Nursing
• Pharmacy
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Slide 59
Q&A Session Press *1 to ask a question
You will enter the question queue
Your line will be unmuted by the operator for your turn
A recording of this presentation will be made available on our website:
www.safehealthcareforeverywoman.org
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Slide 60
Next Safety Action SeriesAssessing Risk for Antenatal Venous
ThromboembolismWednesday, April 20th | 11:30 a.m. Eastern
Michael Paidas, MD, FACOG
Professor & Vice Chair, Obstetrics, Yale
School of Medicine
Liyana Winchell, RN, BSN
Yale-New Haven Hospital
Click Here to Register